Laserfiche WebLink
' SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: M C M 14 -AM/PM Date of Test' 1/ ril Facility Address: 130 S.WILSON WAY STOCKTON, CA 95205Facility Contact: Parminder Phone: 466-6633 <br /> Date Local Agency Was Notified of Testing:12/28/2017 <br /> Name of Local Agency Inspector(f present during testing): HEALTH <br /> 2.TESTING CONTRACTOR INFORMATION DEPA rMENT <br /> Company Name: AFFORDA TEST 416 2"a Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ® Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket (ay Tank 1 87 MASTER 2 91 3 87 SLAVE 4 <br /> Number, Stored Product, etc.) <br /> ❑Direct Bury [I Direct Bury <br /> ❑Direct Bury ❑ Direct Bury <br /> Bqcket Installation Type: ®Contained in Sump ®Contained in Sump ® Contained in ❑Contained in <br /> Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth. 15 15 15 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1124 1124 1124 <br /> Initial Reading(Ri): 11 3/4 11 1/4 11 1/4 <br /> Test End Time(TF): 1224 1224 1224 <br /> Final Reading(RF): 11 3/4 11 1/4 11 1/4 <br /> Test Duration(TF—TI): HR HR HR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature Date:-1-24-17 <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However,local requirements <br /> may be more stringent. <br />