Laserfiche WebLink
Y 1 <br /> R z s E I cul <br /> . , Q,RCB.Jam,ard 2000 <br /> Spill ticket T estiing Report i or,4 ' <br /> This fi n-in is inlended f)r use hY contraciors perlbrnrittg annual testing Of CSl spill containment istructures, The cVINt71('wd la,rin wid <br /> printolits.fi•orrr tests(rfappUcahle), should he provided to thefucilih nwneiioherutor t�'$s�4` pmT .ill r•eguhnor r ar4enc). <br /> 1. FACILITY INFORMATION eiF P. nAI-NT <br /> Facility Name: N& M KWIK SERVE BW98 Date ofTesting: g,'3 1 <br /> Facility Address: 2501 E. JACKSON <br /> Facility Contact: MODESTO — -- Phone: 209-838-3971 _ <br /> Date Local Agency Was Notified ofTesting <br /> Name of Local Agency Inspector(tf present durin7 testing): - <br /> j <br /> _ 2. TESTING CONTRACTOR INFORMATION <br /> Company Name 1-.C'.SFtRVICF'S <br /> Technician Conducting Test: PETER WESTBROOK I <br /> T __4 <br /> Credentials': CSLB Contractor X ICC Service Tech. SWRCB Tank Tester ?Other(Spec►ft) <br /> License Number(s):8772623 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X--Hydrostatic Vacuum Other <br /> Test Equipment Used: WATER Equipment Resolution: TAP 1 <br /> Identify Spill Bucket (,qy Tank 1 87 F[LL 2 91 FILL 3 DIESEL FILL 4 <br /> Number, Stored Product, etc,) <br /> Bucket Installation Type: X Direct Bury X Direct Bury X Direct Bury Direct I3ud s <br /> Contained in Sump Contained inSump Contained in Sump Contained in Sump <br /> Bucket Diameter: 12" 12- 12" — <br /> Bucket Depth: 14" 14" 14" <br /> -- --------- — <br /> Wait time between applying <br /> vacuum/water and start of test: 30-MIN 30-MIN 30-MIN <br /> Test Start Time(Ti): 9:OOAM 9:OOAM 9:OOAM <br /> Initial Reading(R,): 14" 14" 14" p <br /> Test End Time(Ti): 10:00AM 10:OOAM 10:OOAM <br /> Final Reading(R,:): 14•` 4•' 2" <br /> Test Duration(T, T,): i HR I-fiR 1-HR �E <br /> Change in Reading(Rr-R,): NONE -- 10' 12 <br /> Pass/Fail Threshold or PASS FAILED FAILED <br /> Criteria: <br /> Test Result: X Pass Fail Pass X Fail Pass X Fail ❑ Pass 0 Fail - jf <br /> Comments—(inchide information on repairs made prior to testing, w7d recommended faflow-up for foiled tests) <br /> _DSLAND 91 FAILED WILL NEED ETURN FOR REPS IRS_._ <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING; <br /> I herebv certify that all lite Information copetained irr this report is true,accurate,ititd in full co®npliance►villi legal requirements. <br /> Technician's Signature: Date:`-��' '/T <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor, However. local requirements <br /> may be more strin-Ont. <br />