Laserfiche WebLink
0 0 <br />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 F A !`TT 7TV TNTP PfA1D M A'PT"XT <br />Facility Name: RIPON SHELL Date of Testing: 1-24-11 <br />Facility Address: 341 E MAIN ST RIPON CA <br />Facility Contact: ANGLE Phone: 209-599-4454 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (tfpresent during testing): SAN JOQUIN CO. <br />L. I Lb I EN (i UUINTHAC TUR INFORMATION <br />Company Name: AFFORDA TEST 4162 d Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-01 16 1 <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 />i CPTT .T . R1rfirWTP 'P 'PTP VrTIVff Y%T7. r%"xx A mTnXT <br />Test Method Used: ® Hydrostatic ❑ vacuum _ vy El Other 1, <br />Test Equipment Used: TAPE MEASURE, <br />H2O Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 3 91 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />El Contained in Sump <br />Direct Bury <br />❑ Direct Bury ❑ Contained in <br />❑ Contained in Sump <br />sumn <br />❑ Direct Bury <br />El Contained in <br />um <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />Test Start Time (Ti): <br />1320 <br />1320 <br />Initial Reading (Ri): <br />121/8 <br />125/8 <br />Test End Time (TF): <br />1420 <br />1420 <br />Final Reading (RF): <br />12 1/8 <br />125/8 <br />Test Duration (TF — Tj): <br />HR <br />HR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />-- <br />-- <br />Test Restil <br />®. <br />Pass ❑-1yaa1 :. <br />❑ <br />:Pass -` ❑ 1[+`a l <br />Pass' ❑Bail <br />❑Pass ❑Fail <br />`.u.i"■igcilka — (tnctuae injormarton on repairs matte 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: a Date: 1/24/11 <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 />