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: 99 SHELL I Date of Testing: 8-22-17 <br /> Facility Address: 7700 MORELAND RD.STOCKTON,CA 95212 <br /> Facility Contact: ANGLE Phone: 209-957-5398 <br /> Date Local Agency Was Notified of Testing:7-24-17 <br /> Name of Local Agency Inspector(tfpresent during testing): VICKI <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Ed Stearns Zane A.Nimmo ® David A.Winkler ❑ Felix G.Ramirez <br /> 8184188 8211269 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, H 2 0 Equipment Resolution: 1/16" J <br /> Identify Spill Bucket (lay Tank 1 87 2 91 3 DIESEL 2 4 <br /> Number, Stored Product, etc. <br /> El Direct Bury El Direct Bury <br /> Bucket Installation Type: El Direct Bury El Direct Bury ®Contained in El Contained in <br /> ®Contained in Sump ®Contained in Sump Sum Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 14 1/4 16 1/2 16 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 9 9 11 <br /> Initial Reading(Rj): 13.50 15 15 <br /> Test End Time(TF): 10 10 12 <br /> Final Reading(RF): 13.50 15 15 <br /> Test Duration(TF—TI): HOUR HOUR HOUR <br /> Change in Reading(RF-Ri): 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 follo e <br /> OPW - 11 F > <br /> OCT 16 2017 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTINOVIRONMENTn�eA��L��HEALTH <br /> I herebyy certify that all the information contained in this report is true,accurate,and in full compliance with[I��a�Trt+t E9T <br /> Technician's Signature:_._ Date: 8-22-17 <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 />