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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Food 4 Less Date of Testing:2/20/13 <br /> Facility Address: 3408 Manthey Road Stockton, CA 95206- <br /> Facility Contact: Gilbert Silva (209) 234-7869 <br /> Date Local Agency Was Notified of Testing: 2/12/13 <br /> Name of Local Agency Inspector (if present during testing): Garrett Backus <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Myke Briggs <br /> Credentials: ❑X CSLB Contractor ❑X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:8033115-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑X Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 In. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 4 <br /> Number, Stored Product, etc.) 01 Re U 02 Prem <br /> ❑ <br /> Bucket Installation Type: Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ❑X Contained in Sump Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 12.00 In. 12.00 in. <br /> Bucket Depth: 14.00 in. 13.00 in. <br /> Wait time between applying <br /> 1 min. 1 min. <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 10:00am 10:00am <br /> Initial Reading (R, ): 13.500 in. 12.000 in. <br /> Test End Time(TF): 11:00am 11:00am <br /> Final Reading(FBF): 13.500 in. 12.000 in. <br /> Test Duration(TF -T,): 1.00 hr. 1.00 hr. <br /> Change in Reading (RF -R,): 0.0000 In. 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS <br /> Test Result: Pass ❑ Fail ❑x Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments: Replaced 91 Fill Cap - Re-Tested & Passed. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> rR <br /> Technician's Signature: r Date: 2/20/13 <br /> 1 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 />