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: CANEPAS CAR WASH I Date of Testing: 7-1-09 <br /> Facility Address: 6230 PACIFIC AVE STOCKTON CA <br /> Facility Contact: JEFF OR STEVE Phone: 209-478-5515 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(f present during testing): ARIS SJV <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2°d Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ❑ Zane A.Nimmo M 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: H2O&TAPE MEASURE Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 89 3 91 4 DSL <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury <br /> ®Direct Bury ®Direct Bury El Contained in ❑Contained in <br /> Bucket Installation Type: El Contained in Sump ❑Contained in Sump <br /> SUM13Sum <br /> Bucket Diameter: 11 11 11 11 <br /> ` Bucket Depth: 14 14 13.50 14 <br /> Wait time between applying NA NA NA NA <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 900 900 900 900 <br /> Initial Reading(RI): 12 12.25 12 13 <br /> Test End Time(TF): 1000 1000 1000 1000 <br /> Final Reading(RF): 12 12.25 12 13 <br /> Test Duration(TF—T,): 1 HR 1 HR 1 HR IHR <br /> Change in Reading(RF-Rj): 0 0 O 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 1/16 <br /> Criteria <br /> Piss 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: Tz�j Date:7-1-09 <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 />