COMPLIANCE INFO 2017 - 2018 - Laserfiche WebLink

Home Browse Search

SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: WATERLOO FOOD MART Date of Testing: 4/10/2018 Facility Address: 4315 E WATERLOO RD. STOCKTON, CA 95215 Facility Contact: RUPI Phone: Date Local Agency Was Notified of Testing:2/28/2018 Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 Technician Conducting Test: ❑ Ed Stearns ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez 8883080 -UT 8883064 -UT 8883059 -UT 8883072 -UT Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" Identify Spill Bucket (By Tank Number, Stored Product, etc. 1 87 2 3 91 4 Bucket Installation Type: ❑ Direct Bury ®Contained in Sump ❑Direct Bury El Contained in Sump El Direct Bury ® Contained in Sump E] Direct Bury El Contained in Sum Bucket Diameter: ] 1 11 Bucket Depth: 19 20 Wait time between applying vacuum/water and start of test: Test Start Time (TI): 0930 0930 Initial Reading (RI): 16 3/4 17 - Test End Time (TF): 1030 1030 Final Reading (RF): 16 3/4 17 - Test Duration (TF — TI): HR HR Change in Reading (RF - RI): 0 0 Pass/Fail Threshold or Criteria: Test Result: ® Pass ❑ Fail ❑ Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) BUCKETS MEASURED 5 GALLONS + CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: Date: 4/10/2018 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.