Laserfiche WebLink
♦ , RHECEIVED <br /> SWRC , au4 6 <br /> Spill Bucket Testing Report Form ENVIRONMENTAL <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The c mpNeP 1- <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: RIPON SHELL Date of Testing: 1-26-15 <br /> Facility Address: 341 E MAIN ST RIPON CA <br /> Facility Contact: Angle Phone: <br /> Date Local Agency Was Notified of Testing:12-22-14 <br /> Name of Local Agency Inspector(f present during testing): ELENA <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162"d 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': ®ICC Service Tech. ® SWRCB Tank Tester <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury <br /> Direct Bury Direct Bury <br /> ❑Contained in Sump El Contained in Sump ❑Contained in F-1 Contained in <br /> Sump Sum <br /> Bucket Diameter: l 1 11 <br /> Bucket Depth: 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9 9 <br /> Initial Reading(Rj): 12 12 <br /> Test End Time(TF): 10 10 <br /> Final Reading(RF): 12 12 <br /> Test Duration(TF—Tj): IHR IHR <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑Fail E Pass ❑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: "'--j Date 1-26-2015 <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 />