Laserfiche WebLink
SWRCB, January 2006 <br />9. Bucket Testing Repoloorm <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 />FNNFZTQTIRAVJQ!' ! <br />Facility Name: SHELL # 136186 <br />Date of Testing: 02/02/2009 <br />Facility Address: 3725 N. TRACY BLVD TRACY, CA, 95376 <br />Facility Contact: MANAGER <br />Phone: (2 0 9) 835-7608 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (if present during testing): MICHELLE HENRY <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: BRYAN KEYS <br />Credentials 1: <br />❑ <br />CSLB Contractor <br />[] <br />ICC Service Tech. <br />E SWRCB Tank Tester ❑ Other (Spec) <br />License Number: 07-1735 <br />I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />El Hydrostatic <br />Vacuum <br />1:1 Other <br />Test Equipment Used: TEST FLUID, TAPE MEASURE <br />Equipment Resolution: VISUAL <br />Identify Spill Bucket(By Tank <br />Number, Stored Product, etc) <br />1 1 REG FILL <br />Z 1 REG VAPOR <br />3 2 PLU FILL 4 2 PLU VAPOR <br />Bucket Installation Type: <br />Direct Bury <br />❑x Contained in Sump <br />❑ Direct Bury <br />X❑ Contained in Sump <br />E]Direct Bury ❑ Direct Bury <br />® Contained in Sump QX Contained in Sump <br />Bucket Diameter: <br />14 <br />14 <br />14 14 <br />Bucket Depth: <br />14 <br />14 <br />14 14 <br />Wait time between applying <br />vacuum/water and starting test: <br />1 MIN <br />1 MIN <br />1 MIN 1 MIN <br />Test Start Time (TI ): <br />1020 <br />1125 <br />1020 1125 <br />Initial Reading (RI ): <br />13 5/8 <br />13 3/8 <br />13 3/4 13 1/2 <br />Test End Time (TF ): <br />1120 <br />1225 <br />1120 1225 <br />Final Reading (RF ): <br />13 5/8 <br />13 3/8 <br />13 3/4 13 1/2 <br />Test Duration: <br />1 HR <br />1 HR <br />1 HR 1 HR <br />Change in Reading (R F - RI ): <br />0 <br />0 <br />0 0 <br />Pass/Fail Threshold or VISUAL LOSS VISUAL LOSS VISUAL LOSS VISUAL LOSS <br />Criteria: <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECIINICIAN 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 requirement& <br />Technician's Signature: Date: 02/02/2009 <br />I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />