Laserfiche WebLink
11 <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: Econo Gas Date of Testing: 12/11/07 <br />Facility Address: 880 E. Victor Road Lodi, CA 95240 <br />Facility Contact: Singh I Phone: 209-369-0958 <br />Date Local Agency Was Notified of Testing: 11/20/07 <br />Name of Local Agency Inspector (ifpresent during testing): Garrett Backus <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: BZ Service Station Maintenance <br />Technician Conducting Test: <br />Ed Stearns <br />Credentials': X CSLB Contractor X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): <br />433159, 5250492 <br />Test Method Used: <br />3. SPILL BUCKET TESTING INFORMATION <br />X Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Tape Measure <br />Identify Spill Bucket (By Tank 1 87 <br />Number, Stored Product, etc. <br />Bucket Installation Type: X Direct Bury <br />❑ Contained in Sump <br />2 91 <br />X Direct Bury <br />❑ Contained in Sump <br />Equipment Resolution: <br />..................... <br />3 Diesel 4 <br />X Direct Bury ❑Direct Bury <br />❑ Contained in Sump ❑ Contained in Sum <br />Bucket Diameter: <br />12" <br />12" <br />12" <br />Bucket Depth: <br />14" <br />14" <br />14" <br />Wait time between applying <br />vacuum/water and start of test: <br />0 <br />0 <br />0 <br />Test Start Time (T,): <br />2:00 <br />2:00 <br />2:00 <br />Initial Reading (R): <br />13" <br />13" <br />13" <br />Test End Time (TF): <br />3:00 <br />3:00 <br />3:00 <br />Final Reading (RF): <br />13" <br />13" <br />13" <br />Test Duration (TF — TO: <br />1 hour <br />1 Hour <br />1 hour <br />Change in Reading (RF—R,): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />0 <br />Test Resttit ! I Fasa Cl Fail Fass' I� Fail X Fars ©Fail L7 Puss ❑;Fad .: <br />Comments— (include information on repairs made prior to testing and recommended follow-up forfailed tests) <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: Date_12/11/07 <br />' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />may be more stnn gent. <br />