Laserfiche WebLink
11/30/2009 16:32 FAX 2093683234 GEORGE RISHIDA INC 191008 <br />SWRC13, January 2006 <br />Spill Bucket Teting epoirt Form <br />This form is intended for^ use by contractors perforating annuli testing of UST spill containment structures. The completed form and <br />printouts from tests (if applicable), should be provided to the fErcilin, owner/operatorfor submittal to the local regulatory ageno) <br />1. FACILITY INFORMATION <br />Facility Name: _ KISHIDA TRUCKING Date of Testing: I 1-06-09 <br />facility Address: 1725 ACKERMAN DRIVE <br />Facility Contact: KELLIE Phone: 209-3680603 _ <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (fpresent during testing): SAN JOAQUIN CO RAY VON FLUE <br />Company Name: AFFORDA TEST 416 2nd Street talt, CA 95632 (209) 744-0112 Fax, (209) 744-0116 <br />Technician Conducting rest: ❑ Lyle D. Nimmo ❑ Zine A. Nimmo ❑ David A. Winkler ® Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': ® ICC Service Tech. ® SWRCS Tanlc Te er <br />a curt r nrT11W ' r �Tw.qwvn vm1wnR 4.&-rmN <br />Test Method Used: ® Hydrostatic ❑ *aeuum ❑ Other <br />Test Equipment Used: TAPE H2O <br />Equipment Resoiution: 1/16 <br />.:..,...,..:..,.,....„.........,, ... . <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />1 DIE <br />2 TE <br />3 4 <br />Bucket Installation Type: <br />CD Direct Bury <br />❑ Contained in Sump <br />®Direct Bury <br />❑ Contained in Sump <br />Direct Bury ❑ Direct Bury <br />❑ Contained in ❑ Contained in <br />Sum Sum <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />18 <br />18 <br />Wait time between applying <br />vacuum/water and start of test; <br />Test Start Time (T,): <br />1 100 <br />1 10 Q <br />initial Reading (111): <br />17 1/2 <br />171 2 <br />Test End Time (TF): <br />1200 <br />1200 <br />Final Reading (.RF): <br />17 1/2 <br />17 1/12 <br />Test Duration (TR T Tj): <br />1 HOUR <br />1 H UR <br />Change in Reading (RF -R,): <br />0 <br />0 <br />•P.ass/F-ail Thrasl�eldor- - <br />Criteria: <br />0 • - _ <br />00 <br />0 <br />Test Result- <br />Pass ❑ Fzail . <br />®Pass ❑ Fail <br />[] 'Pass ❑ Fail ❑ Pass [f .Fail <br />Comnnents — (include mforrmation on repairs made prior to testing and recommendedfollow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE F04 CONDUCTING THIS TESTING <br />I hereby certify that all the information ccoontained in this report is rue. accurate, and in full compliance with legal requirements. <br />Technician's Signature: Date: 11-6-09 <br />' State laws and regulations do not currently require testing to bperformed by a qualified contractor. However, local requirements <br />may be more stringent. <br />