Laserfiche WebLink
6 0 OOZE <br />�vc <br />s.s.Ms <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 />I- FACILITV INFORMATION <br />Facility Name: California Stop I Date of Testing: 03/17/2010 <br />Facility Address: 2224 S Manthey Stockton, CA 95206 <br />Facility Contact: Nancy Lee Phone: 209-462-7621 <br />Date Local Agency Was Notified of Testing: - <br />Name of Local Agency Inspector (fpresent during testing): - <br />Company Name: EPIC Com liance Systems, Inc. <br />Technician Conducting Test: Keith Huston <br />Credentials': 21 CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 880430 <br />Test Method Used: ❑ Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: - <br />Equipment Resolution: - <br />identify Spill Bucket (By Tank 1 <br />Number, Stored Product, etc. Regular <br />2 <br />Premium <br />3 4 <br />Dieser <br />Bucket Installation Type: 0 Direct Bury <br />❑ Contained in Sump <br />0 Direct Bury <br />❑ Contained in Sump <br />0 Direct Bury ❑ Direct Bury <br />❑ Contained in Sump ❑ Contained in Sum <br />Bucket Diameter: 12" <br />12" <br />12" <br />Bucket Depth: 14" <br />14" <br />14 1/2" <br />Wait time between applying 5 min <br />vacuum/water and start of test: <br />5 min <br />5 m i n <br />Test Start Time (Ti): 01:.10- PM <br />01:10 PM <br />01:10 PM <br />Initial Reading (RI): 123/4 <br />12 11/16 <br />127/8 <br />Test End Time (TF): 02:10 PM <br />02:10 PM <br />02:10 PM <br />Final Reading (RF): 12 3/4 <br />12 11/16 <br />127/8 <br />Test Duration (TF — TI): 1 hr <br />1 hr <br />l hr <br />Change in Reading (RF - RI): 0 <br />0 <br />0 <br />Pass/Fail Threshold or 0 <br />Criteria: <br />0 <br />0 <br />"rest Result: ® Pass . Ufail <br />�-99 Pass ❑ Fail <br />0 Pass:. ® Fair ® 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: 03/17/2010 <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 />