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 owneNoperator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Tracy Blvd Shell & Mini Mart Date ofTesting: 01/25/17 <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: 12/26/16 <br />Name of Local Agency Inspector (ffpresent during testing): Vicki McCartney <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Service Station Systems... <br />Technician Conducting Test: Kris Bell <br />Credentials : ❑X CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): License:485184 ICC:5297793-UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />® Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: Measuring Tape <br />Equipment Resolution:) /16 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 Fill Bucket <br />01 - Re u <br />2 i uc et <br />02 - Plus <br />3 Fill Bucket <br />03- <br />4 Fill Bucket <br />04 - Diesel <br />Bucket Installation Type: <br />❑ Direct Bury <br />❑X Contained in Sump <br />❑ Direct Bury <br />® Contained in Sump <br />F-1Direct Bury <br />® Contained in Sump <br />❑ Direct Bury <br />® Contained in Sump <br />Bucket Diameter: <br />13.00 in. <br />13.00 in. <br />13.00 in. <br />13.00 in. <br />Bucket Depth: <br />15.00 in. <br />15.00 in. <br />13.50 in. <br />14.00 in. <br />Wait time between applying <br />v <br />vacuum/water and start of test: <br />10 min. <br />10 min. <br />10 min. <br />10 min. <br />Test Start Time (T, ): <br />9:17am <br />10:56am <br />9:17am <br />9:17am <br />Initial Reading (F r ): <br />13.938 in. <br />13.875 in. <br />12.875 in. <br />13.313 in. <br />Test End Time (TF ): <br />10:17am <br />11:56am <br />10:17am <br />10:17am <br />Final Reading (IAF ): <br />13.938 in. <br />13.875 in. <br />12.875 in. <br />13.313 in. <br />Test Duration (TF: - TI): <br />1.00 hr. <br />1.00 hr. <br />1.00 hr. <br />1.00 hr. <br />Change in Reading (RF - RI ): <br />0.0000 in. <br />0.0000 in. <br />0.0000 in. <br />0.0000 in. <br />Pass/Fail Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />Test Resuilt: <br />®Pass ❑ Fait <br />®Pass ❑ Fail <br />[g] Pass ❑ Fail <br />® Pass ❑ Fail <br />Comments: 89 Failed, Replaced Cap & Adaptor. Retested, Passed <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />/ hereby certify that all the InNavaliap contained in this report is true, accurate and in full compliance with legal requirements. <br />Technician's <br />Date: 01/25/17 <br />t 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 />