COMPLIANCE INFO_2013-2017 - Laserfiche WebLink

Home Browse Search

n Y 2 4VOO, January 2006 Spill Bucket Testing Report Form 4 , This form is intended for use by contractors performing annual testing of LIST spill containment sSIA6- h-1kh`'�`&M-hpteted form and printouts from tests (if applicable) should be provided to the facility owner/operator for submittal to the local regulatory agency 1. FACILI'T'Y INFORMATION Facility Name: UNITED #5446 Date of Testing: 511112016 Facility Address: 1403 COUNTRY CLUB BLVD, STOCKTON, CA 95204 Facility Contact: ALLEN FAASS I Phone: (949) 289-5286 Date Local Agency Was Notified of Testing: 4122116 Name of Local Agency Inspector (rfpresent during testing): COUNTY OF SAN JOAQUIN ENV HLTH INSPECTOR 2. TESTING CONTRACTOR INFORMATION Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Technician Conducting Test: RICHARD THOMAS Credentials: ® CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) License Number(s): 803705 (CSLB Contractor) - 5254736 -UT (ICC Service Tech) - 06-1672 (SWRCB Tank Tester) 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other (Spec) Test Equipment Used: VISUAL - TAPE MEASURE Equipment Resolution: 1/16" Identify Spill Bucket (By Tank Number, Stored Product, etc.) DIESEL FILL 87 FILL 91 FILL Bucket Installation Type: ® Direct Bury ❑ Contained in Sump ® Direct Bury ❑ Contained in Sump ® Direct Bury ❑ Contained in Sump ❑ Direct Bury ❑ Contained in Sump Bucket Diameter: 12" 12" 12" Bucket Depth: 12.25" 12" 11.50" Wait time between applying 10 MIN vacuum/water and start of test: 10 MIN 10 MIN Test Start Time (Ti): 10:00 10:00 10:00 Initial Reading (Ri): 10.75 10.50" 10" Test End Time (TF): 11:00 11:00 11:00 Final Reading (RF): 10.75" 10.50" 10" Test Duration (TF — T,): 1 HR 1 HR 1 HR Change in Reading (RF- Ri): 0 0 0 Pass/Fail Threshold or Criteria: NO LOSS NO LOSS NO LOSS NO LOSS Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fair ❑ Pass ❑ Fail Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information ,^ contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: f --I "tAA`---'� Date: 5/1112016 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.