Laserfiche WebLink
r <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of LIST spill containment structures. The completed form and <br /> printouts from tests(tf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: SJC SHERIFFS OP Date of Testing: 1-21-2011 <br /> Facility Address: 7000 N MICHAEL CANLISS RD FRENCH CAMP CA <br /> Facility Contact: Phone: <br /> LDate Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(fpresent during testing): MICHELLE <br /> 2.TESTING CONTRACTOR INFORMATION <br /> FCompany Name: AFFORDA TEST 416 2nd 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 /> =MethodUsed: ®Hydrostatic ❑Vacuum ❑ Other <br /> nt Used: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 DSL 3 4 <br /> Number, Stored Product, etc. <br /> Direct Bury Direct Bury <br /> Bucket Installation T ®Direct Bury ®Direct Bury <br /> Type: ❑Contained in Sump E] Contained in Sump El Contained in El Contained in <br /> SUMP Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 14 13 <br /> Wait time between applying <br /> vacuum/water and start of test: -" <br /> Test Start Time(Tj): 9 9 <br /> Initial Reading(Rj): 13 12 <br /> Test End Time(TF): 10 10 <br /> Final Reading(RF): 13 12 <br /> Test Duration(TF—Tj): IHR IHR <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass/ ail Threshold or 1/16 1/16 <br /> Criteria: <br /> Test Result: Pass ❑: a bass ❑ 'atC Pass ❑Fal ( `]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: Date 1-21-2011 <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 />