Laserfiche WebLink
SWRCB,January 2006 <br /> SR 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(if applicable),should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> I Date of Testing:.__ 4/29/2015 <br /> Facility Name: TRACY TRUCK&AUTO <br /> Facility Address: 3940 TCY BL , TCY,CA 95304 1 � I I It I".- 11 11 <br /> RAVDRA L <br /> Facility Contact: DEBBIE AND CJ Phone: 209-680332-5006 <br /> Date Local Agency Was Notified of Testing: 4/13/2015 <br /> [ HEHNRName of Local Agency Inspector(ii(present during testing): MCLLE EY <br /> WRONMENl <br /> 2. TESTING CONTRACTOR INFORMATION <br /> U` <br /> Company Name: KAISER COMMERCIAL PETROLEUM <br /> Technician Conducting Test: GREG KAISER <br /> Credentials': 0 CSLB Contractor N ICC Service Tech. 0 SWRCB Tank Tester 0 Other(Specify) <br /> License Number(s): CSLB#859535,ICC#5252318-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: 0 Hydrostatic 0 Vacuum 0 Other <br /> T <br /> U 2" Resolution: <br /> Test Equipment Used:TAPE MEASURE AND Hao Equipment <br /> Bucket Tank T 1 REG UNL <br /> u t y T I <br /> R 3 DIESEL 4 TANK 4 DIESEL <br /> Identify' Spill Bucket(By Tank 1 TANK 1 REG UNL 2 TANK 2 SUPE 3 TANK <br /> Number, <br /> . Stored <br /> P etc. WEST EAST <br /> Number, StoredProduct, etc. <br /> :t- Z Direct Bury N Direct Bury S Direct Bury 9 Direct Bury <br /> 0 Cont Sum <br /> Bucket Installation Type: 0 Contained in <br /> 0 Contained in Sump 0_Contained in Sump 0 Contained in Sum <br /> Bucket Diameter: 11 INCH 11 INCH 11 INCH — 11 INCH <br /> Bucket Depth: 13 INCH 13 INCH 12 INCH 12 INCH <br /> Wait time between applying <br /> vacuum/water and start of test: 9:00 9:00 9:00 <br /> Test Start Time(TO: 9:00 11 INCH 12 INCH 12 INCH <br /> Initial Reading(110: 11 INCH 10:00 10:00 10:00 <br /> Test End Time(TF): 10:00 11 INCH 12 INCH 12 INCH <br /> Final Reading(RF): 11 INCH I HOUR I HOUR I HOUR <br /> Test Duration(TF—TI): I HOUR <br /> Change in Reading(RF-Rt): 0 0 0 0 <br /> Pass/Fail Threshold or PASS PASS PASS PASS <br /> I Criteria: <br /> Test Result: 0 Pas 0 Fail 0 Pass 0 Fail Pass 0 Fail 0 Pass 0 Fail <br /> Comments— (include information on repairs made prior to testing, and recommendedfollow-up for failed tests) - <br /> NOTE: Test water was j21cd in drum— on sitelabeled, sealed for removal per <br /> customer. <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 fill compliance with legal requirements. <br /> Technician's Signature: Date: 4/29/2015 <br /> State laws and regulations do not carr re uire testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. I <br />