Laserfiche WebLink
d + p y <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.FACILITY INFORMATION <br /> Facility Name: WATERLOO GAS&LIQUOR 76 Date of Testing: 10-19-2010 <br /> Facility Address: 5611 E WATERLOO RD STOCKTON CA <br /> Facility Contact: PAUL Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(f present during testing): GARRET <br /> 2. TESTING CONTRACTOR INFORMATION <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': ® 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 DSL 4 <br /> Number, Stored Product, etc.) <br /> ®Direct Bury ®Direct Bury ®Direct Bury El Direct Bury <br /> Bucket Installation Type: ❑ Contained in r]Contained in <br /> El Contained in Sump ❑ Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth. 10 12 12 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 12 12 12 <br /> Initial Reading(Rj): 9.50 11 11 <br /> Test End Time(TF): I 1 1 1 <br /> Final Reading(RF): 9.50 11 11 <br /> Test Duration(TF—TI): IHR IHR 1 HR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail Z 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: Tc-�—j Date 10-19-2010 <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 />