Laserfiche WebLink
RECT JUL 2 7 Z015 <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(if 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: 07-02-15 <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:6-23-15 <br /> Name of Local Agency Inspector(if present during testing): SAN JOAQUIN CO STACI <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd 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 /> Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: TAPE H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 DIE 3 4 <br /> Number, Stored Product, etc. <br /> ® Direct Bury ®Direct Bury ❑Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ❑ Contained in El Contained in <br /> ❑ Contained in Sump [I Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 900 900 <br /> Initial Reading(RI): 13 1/2 13 1/2 <br /> Test End Time(TF): 1000 1000 <br /> Final Reading(RF): 13 1/2 13 1/2 <br /> Test Duration(TF—TI): 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Test Result: Z Pass ❑Fail Z'Pass ❑Fail ❑ Pass ❑Fail ❑ Pass []Vail <br /> Comments—(include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> ®PW 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: 7-2-15_ <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 />