Laserfiche WebLink
0 0 <br />SWRCB, January 2006 <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 (tf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: KNIFE RIVER DSS I Date of Testing: 07-27-12 <br />Facility Address: 655 WEST CLAY AVE STOCKTON CALIFORNIA <br />Facility Contact: JOHN Phone: 209-948-0302 <br />Date Local Agency Was Notified of Testing :07-01-09 <br />Name of Local Agency Inspector (if present during testing): SAN JOAQUIN CO JEFF W ONG <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 "d 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 />NCredentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />® Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: TAPE H2O <br />Equipment Resolution: <br />1/16 <br />1 87 <br />2 DIE <br />3 <br />4 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Bucket Installation Type:F]Contained <br />® Direct Bury <br />ElContained in Sump <br />® Direct Bury <br />ElContained in Sump <br />Direct Bury <br />in <br />SumpSum <br />❑ Direct Bury <br />ElContained in <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />14 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />900 <br />900 <br />Initial Reading (Ri): <br />14 <br />14 <br />Test End Time (TF): <br />1000 <br />1000 <br />Final Reading (RF): <br />14 <br />14 <br />Test Duration (TF — Tj): <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />0 <br />0 <br />Test Result: <br />® Pass ❑ Fail <br />1 ® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />OPW BUCKETS <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: 7-27-12 <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 />