Laserfiche WebLink
Eatl-GiY@i4 GOMS'kAkCE <br /> ec(?� <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: Shell I Date of Testing: 02/28/2017 <br /> Facility Address: 16500 S. Harlan Road, Lathrop,CA 95330 <br /> Facility Contact: Chris I Phone: (209)98 <br /> Date Local Agency Was Notified of Testing: 02/01/2017 <br /> Name of Local Agency Inspector(f present during testing): Stacy Rivera <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ECO-CHEK Compliance, Inc. tINVIROMMEM IAL <br /> Technician Conducting Test: Nik Zagorov NEA- <br /> TH DEPARTMENT <br /> Credentials': Z CSLB Contractor Z ICC Service Tech. Z SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 958763 A <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Z Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used:Tape Measure Equipment Resolution: 1/16 Inches <br /> Identify Spill Bucket(By Tank 1 Regular 2 Premium 3 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: Z Direct Bury Z Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑ Contained in Sum ❑Contained in Sump Contained in Sump Contained in Sum <br /> Bucket Diameter: 12 Inches 12 Inches <br /> Bucket Depth: 14 Inches 14 Inches <br /> Wait time between applying 10 Minutes 10 Minutes <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 09:45 AM 09:45 AM <br /> Initial Reading(Rj): 131/4 Inches 12 3/4 Inches <br /> Test End Time(TF): 10:45 AM 10:45 AM <br /> Final Reading(RF): 13 1/4 Inches 12 3/4 Inches <br /> Test Duration(TF—TI): 60 Minutes 60 Minutes <br /> Change in Reading(RF-RI): 0 Inches 0 Inches <br /> Pass/Fail Threshold or 1/16 Inches 1/16 Inches <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® 'i 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: V-C>V Date:02/28/2017 <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 />