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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: SUPER STOP I Date of Testing: <br /> Facility Address: 290 N MAIN STREET MANTECA CA <br /> Facility Contact: Mandeep Phone: (209)239-4475 <br /> Date Local Agency Was Notified of Testing: 3-27-15 <br /> Name of Local Agency Inspector(fpresent during testing): ELENA <br /> 2.TESTING CONTRACTOR INFORMATION W;7AI V 6. T4AChi- , <br /> Company Name: AFFORDA TEST 4162 nd Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ❑ Zane A.Nimmo ® David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': Z ICC Service Tech. Z 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 91 3 DSL 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury ®Direct Bury ❑Direct Bury <br /> Bucket Installation Type: F-1 Contained in F1 Contained in <br /> r-1 Contained in Sump El Contained in Sump Sum Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 15 15 12 <br /> Wait time between applying NA NA NA NA <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 9 9 9 <br /> Initial Reading(RI): 14 14 11 <br /> Test End Time(TF): 10 10 10 <br /> Final Reading(RF): 14 14 11 <br /> Test Duration(TF—Tj): 1 HR 1 HR 1 HR <br /> Change in Reading(RF-RI): 0 0 O <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> TestAMR: Ptss ❑Fail Pass FailE] Pass Q Fail I ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> Flappers opw <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: 4-29-15 <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 />