Laserfiche WebLink
SWRCB,January 2006 <br /> 9. SO Bucket Testing Reportl&rm <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 owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: COSTCO LOD I Date of Testing: 05/27/2011 <br /> Facility Address: 322 E. HARVEY LANE LODI, CA, 95240 <br /> Facility Contact: MANAGER Phone: (2 0 9) 964-0180 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): RAY VON FLUE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KRISTOPHER BELL <br /> Credentials): CSLB Contractor E ICC Service Tech. ❑SWRCB Tank Tester E Other(Specify) CONTRACTOR <br /> License Number: 7 4 316 0 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [j] Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used:TAPE MEASURE Equipment Resolution:NO VISIBLE LOSS <br /> Identify Spill Bucket(By Tank 1 1 REG FILL 2 1 REG VAPOR 3 2 REG FILL 4 2 REG VAPOR <br /> Number,Stored Product, etc) <br /> F]Direct Bury El Direct Bury El Direct Bury ❑Direct Bury <br /> Bucket Installation Type: Q Contained in Sump X❑Contained in Sump X❑Contained in Sump ❑X Contained in Sump <br /> Bucket Diameter: 1311 1311 1311 1311 <br /> Bucket Depth: 14 1/211 16 11 1411 1511 <br /> Wait time between applying 5 MIN 5 MIN 5 MIN 5 MIN <br /> vacuum/water and starting test: <br /> Test Start Time(Tl ): 11:30 11:30 11:30 11:30 <br /> Initial Reading(RI ): 14 1/211 16" 1411 1511 <br /> Test End Time(TF): 12-30 12:3 0 12:3 0 12:3 0 <br /> Final Reading(R F ): 14 1/211 16" 1411 1511 <br /> Test Duration: 1 HR 1 HR 1 HR 1 HR <br /> Change in Reading(R F-RI ): <br /> 0" 0" 0" 0" <br /> Pass/Fail Threshold or 0" 01, 0 it Off <br /> Criteria: <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 /> f�—t 05/27 2011 <br /> Technician's Signature: -- �-�--- Date: / <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />