Laserfiche WebLink
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 />•' a <br />Facility Name: Tracy Blvd Shell & Mini Mart A Date of Testing: l/30/14 <br />Facility Address: 3725 N. Tracy Blvd. Tracy, CA 95376 <br />Facility contact: Tanya Moore (209) 835-7608 <br />Date Local Agency Was Notified of Testing: 1/22/14 <br />Name of Local Agency Inspector (if present during testing): Thuy Tran <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Service Station Systems <br />Technician Conducting Test: Steve Parmenter <br />Credentials: Q CSLB Contractor Q ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): License: 485184 ICC:531 1561 -LIT <br />Test Method Used: <br />Q Hydrostatic <br />❑ vacuum <br />❑ Other <br />Test Equipment Used: Measuring Tape <br />Equipment Resolution: 1 /16 in. <br />Identify Spilt Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 Fill Bucket <br />01 Re u <br />2 Fill Bucket <br />02 Plus <br />3 Fill Bucket <br />03 Prem <br />4 Fill Bucket <br />04 Diesel <br />Bucket Installation Type: <br />❑ Direct Bury <br />Q Contained in Sump <br />❑ Direct Bury <br />Q Contained in Sump <br />E]Direct Bury <br />Q Contained in Sump <br />❑ Direct Bury <br />Q Contained in Sump <br />Bucket Diameter: <br />12.00 in. <br />12.00 in. <br />12.00 in. <br />12.00 in. <br />Bucket Depth: <br />13.00 in. <br />13.00 in. <br />13.00 in. <br />13.00 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />1 min. <br />1 min. <br />1 min. <br />1 min. <br />Test Start Time (Ti ): <br />9:06am <br />9:06am <br />9:06am <br />9:06am <br />Initial Reading (R, ): <br />13.000 in. <br />13.000 in. <br />13.000 in. <br />13.000 in. <br />Test End Time (TF ): <br />10:06am <br />10:06am <br />10:06am <br />10:06am <br />Final Reading (r� ): <br />13.000 in. <br />13.000 in. <br />13.000 in. <br />13.000 in. <br />Test Duration (TF -T1): <br />1.00 hr. <br />1.00 hr. <br />1.00 hr. <br />1.00 hr. <br />Change in Reading (RF - R1 ): <br />0.0000 in. <br />0.0000 in. <br />0.0000 in. <br />0.0000 in. <br />Pass /Fail Threshold or Criteria: 11 <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />Test Result:Q <br />Pass ❑ Fail <br />Q Pass E] Fail <br />Q Pass 0 Fail <br />Q 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 />/ 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: 1/30/14 <br />I 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 />