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: STOCKTON USD Date of Testing: 05-07-10 <br /> Facility Address: 1932 EL PINAL DR <br /> Facility Contact: BUTCH Phone: 209-933-7045 <br /> Date Local Agency Was Notified of Testing:04-20-10 <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO. <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd 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/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 DIE 3 4 <br /> Number, Stored Product, etc.) <br /> ❑Direct Bury ❑ Direct Bury ❑Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ®Contained in Sump ® Contained in Sump ❑Contained in ❑Contained in <br /> Sump Sump <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 15 15 <br /> Wait time between applying _ <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1305 1305 <br /> Initial Reading(Rj): 14 137/8 <br /> Test End Time(TF): 1405 1405 <br /> Final Reading(RF): 14 137/8 <br /> Test Duration(TF—Tj): 1 HOUR 1 HOUR <br /> Change in Reading(RF-Rj): 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:5-7-10 <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 />