Laserfiche WebLink
Spill Bucket Testing Report Form MAR 112016 <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printoutsfrom tests(ifopplicable), should be provided to the facilityowner/operatorfor submittal to theENWONWRTAL <br /> 1. FACILITY INFORMATION urplTu nr_o9oTgern1T <br /> Facility Name: TOKAY SHELL Date of Testing: 1/20/2016 <br /> Facility Address: 420 W.KETTLEMAN LN. LODI,CA 95240 <br /> Facility Contact: JAS Phone: 209-369-2790 <br /> Date Local Agency Was Notified of Testing:12/22/15 <br /> Name of Local Agency Inspector(ifpresent during testing): ARIS CACAPIT <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: ❑Lyle D.Nimmo ® Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentialsi: ®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(By Tank 1 87 2 91 3 100 OCT 4 DIESEL/ <br /> Number,Stored Product, etc.) WASTE OIL <br /> ®Direct Bury ®Direct Bury <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury ❑Contained in ❑ Contained in <br /> ❑ Contained in Sump ❑Contained in Sump SumpSum <br /> Bucket Diameter: 11 11 11 11 --- 11 <br /> Bucket Depth: 12 14 13 13 --- I l <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 0840 0840 0840 0840 -- 0955 <br /> Initial Reading(Rt): 11 1/2 12 1/4 12 3/4 12 3/4 --- 10 1/4 <br /> Test End Time(TF): 0940 0940 0940 0940 --- 1055 <br /> Final Reading(RF): 11 1/2 12 1/4 12 3/4 12 3/4 --- 10 1/4 <br /> Test Duration(TF—Tj): HR FIR HR HR --- HR <br /> Change in Reading(RF-R[): 0 0 0 0 --- 0 <br /> Pass/Fail Threshold or PASS --- PASS <br /> Criteria: <br /> Test Result: ® Pass ❑Fail I ® Pass ❑Fail ® Pass ❑ Fail ® Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing and recommended follow-up for jailed tests) <br /> WASTE OIL AND DIESEL SPILL BUCKETS IN SAME COLUMN <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:-1-20-16— <br /> State <br /> ate: 1-20-16State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />