Laserfiche WebLink
SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />Thisform is intended for use by contractors performing annual testing of UST spill containment .structures. The completed,form m and <br />printouts fi-orn tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />r. A d"rT irry irml7niDMATInN <br />[ENameof <br />EL DORADO FOOD SHELL Date of Testing: 02-08-i l <br />ss: 2320 NORTH ELDORADO BLVD STOCKTON CALIFORNIA95204 _ <br />ct BOB Phone: 209-943-1311 <br />gency Was Notified of Testing: <br />l Agency Inspector (f present during testing): SAN JOAQUIN CO GARRETT <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 />m rnTT['�TTI►T!"� TATTlIUAX A TTl1N <br />• J. O.F1ju iDV `.1'.e:ul leJvaaa.v s+�——w•r--- —- � —= <br />❑ ❑ I <br />Test Method Used: ® Hydrostatic Vacuum Other <br />Test Equipment Used. TAPE H2O Equipment Resolution 1/16 <br />1 87 <br />®Direct Bury <br />❑ Contained in Sump <br />2 91 <br />®Direct Bury <br />❑ Contained in Sump <br />3 DIE <br />® Direct Bury <br />❑ Contained in <br />SumpSum <br />4 <br />❑ Direct Bury <br />❑ Contained in <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Bucket Installation Type: <br />11 <br />11 <br />11 <br />_ <br />Bucket Diameter: <br />13 <br />13 <br />13 <br />_ - <br />Bucket Depth: <br />_ <br />- <br />- <br />— <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Tj): <br />930 <br />930 <br />930 <br />12 <br />12 <br />11 1/4 <br />Initial Reading (Rj): <br />1030 <br />1030 <br />1030 <br />Test End Time (TF): <br />12 <br />12 <br />11 1/4 <br />Final Reading (RF): <br />Test Duration (TF — Ti): <br />1 HOUR <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - Rj): <br />0 <br />0 <br />0 <br />-- <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />0 <br />I M Pass ❑Fail <br />0 <br />Pass ' ❑ Fail <br />0 <br />[D Pass ❑Fail <br />❑ Pass ❑ Fail <br />Comments —(include information on repairs made prior to testing, ana recommenaea joitow-up juf juueu -alav _ <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: <br />Date: <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 />