Laserfiche WebLink
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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: SHOP N GO Date of Testing: 2-27-2017 <br />Facility Address: 4511 PACIFIC AVE STOCKTON CA <br />Facility Contact: RAY Phone: 952-0001r. y z r <br />_.. <br />Date Local Agency Was Notified of Testing :1-31-17 <br />Name of Local Agency Inspector (f present during testing): VICKI A P R 2 4 2017 <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) <br />a T <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ® David A. Winkler ❑ Fe 2x G: ka'miiez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester I <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank 1 87 2 91 3 4 <br />Number Stored Product, eta) <br />Bucket Installation Type: <br />® Direct Bury <br />❑Contained in Sump <br />Direct Bury <br />® Direct Bury F1 Contained in <br />❑Contained in Sump Sump <br />Direct Bury <br />F1 Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />14 <br />16 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TI): <br />1 <br />1 <br />Initial Reading (RI): <br />14 <br />16 <br />Test End Time (TF): <br />2 <br />2 <br />Final Reading (RF): <br />14 <br />16 <br />Test Duration (TF — Tc): <br />IHR <br />IHR IHR <br />Change in Reading (RF - Rj): <br />0 <br />0 0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 1/16 <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />®PW FLAPPERS <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I bereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: T��Date 2-27-17 <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 />