Laserfiche WebLink
+`ItM,January 2006 <br /> Spill Bucket Testing Report Form p 5 Z o <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 (:f applicable), should be provided to the facility owner/operator for submittal'jo4?he,f W 1-regulatory agency- <br /> 1. <br /> - - <br /> 1.FACILITY INFORMATION <br /> Facility Name: JESSE & KUL PETRO ARCO <br /> Date of Testing: 6/13/2016 <br /> Facility Address: 1711 E. YOSEMITE AVE MANTECA, CA 95336 <br /> Facility Contact: <br /> Phone: <br /> Date Local Agency Was Notified of Testing:5/25/2016 <br /> Name of Local Agency Inspector(f present during testing: VICKIE <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"a Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> ❑Lyle D.Nimmo ® Zane A.Nimmo ❑ David A. Winkler ❑ Felix G.Ramirez <br /> Technician Conducting Test: 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ®ICC Service Tech. ® SWRCB Tank Tester <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Hydrostatic H ❑Vacuum ❑Other <br /> Test Method Used: ® Y <br /> Test Equipment Used: TAPE MEASURE, H2O <br /> Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 <br /> 2 87-2 3 91 4 <br /> red Product <br /> b <br /> Numer, stored etc. Direct B <br /> - Direct Bury ❑ m'Y <br /> Direct B <br /> ' ❑Direct Bury �' ®Contained in El Contained in <br /> Bucket Installation Type: <br /> ®Contained in Sump ®Contained in Sump Sum Sum <br /> . 11 11 11 <br /> Bucket Diameter: <br /> Bucket Depth: <br /> 12 1/4 12 12 1/4 <br /> Wait time between applying '- <br /> vacuum/water and start of test: 1420 <br /> 11 1 <br /> Test Start Time(Ti): 11 1 1/2 11 1 1 1 <br /> /8 11 3/4 <br /> Initial Reading(Ri): <br /> Test End Time(TF): <br /> 1520 1520 1520 <br /> Final Reading(RF): <br /> 11 1/2 11 1/8 11 3/4 <br /> Test Duration(TF—Tt): HR <br /> HR HR <br /> Change in Reading(RF-RI): 0 <br /> 0 0 <br /> Pass/Fail Threshold or _ -- -- -- <br /> - include in ormation on repairs made prior to testing, and recommended follow u or <br /> COIIIIIleIItS (inc <br /> f - p f 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: 6-20-16 <br /> However,local requirements may be more stringent. <br />