Laserfiche WebLink
0 <br />SWRCB, January 2006 <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 INFO TION <br />Facility Name: Country Club Mini Date of Testing: 2/25/2013 <br />Facility Address: 1856 Country Club Blvd, Stockton, Ca. 95204 <br />Facility Contact: Phil I Phone: (209) 941-2766 <br />Date Local Agency Was Notified of Testing: b ?-- 14— 13 <br />Name of Local Agency Inspector (af present during testing): Garrett Backus <br />Company Name: Reliable Petroleum Services, Inc. <br />Technician Conducting Test: Guadalupe Sanchez <br />Credentials': x CSLB Contractor x ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 883706 5250451 -UT <br />Test Method Used: xHydrostatic ❑ Vacuum ❑ Other <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 Tl: 91 Fill <br />2 T2: 87 Fill <br />3 T3: <br />4 T4: <br />Bucket Installation Type: <br />Direct Bury <br />x Contained in Sump <br />x Direct Bury <br />❑ Contained in Sum <br />Direct Bury <br />❑ Contained in Sump <br />Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />12" <br />12" <br />Bucket Depth: <br />131/4" <br />13" <br />Wait time between applying <br />vacuum/water and start of test: <br />I minute <br />1 minute <br />Test Start Time (Ti): <br />09:41 a.m. <br />09:50 a.m. <br />Initial Reading (R,): <br />12 5/8" <br />121/4" <br />Test End Time (TF): <br />10:41 a.m. <br />10:50 a.m. <br />Final Reading (RF): <br />12 5/8" <br />121/4" <br />Test Duration (TF— TI): <br />1 hr <br />lhr <br />Change in Reading (RF- RI): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16" <br />1/16" <br />TestResult: <br />x Pass 0 Fail <br />x Pass ❑ Fail <br />Pass ❑ Fail <br />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 Signa Date 2/25/2013 <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 />