Laserfiche WebLink
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 (f 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: 12-23-09 <br /> Facility Address: 880 VICTOR ROAD <br /> Facility Contact: MR SINGH Phone: 209-369-0958 <br /> Date Local Agency Was Notified of Testing: 12-15-09 <br /> Name of Local Agency Inspector(f present during testing): CHEA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: BZ Service Station Maintenance <br /> Technician Conducting Test: ED STEARNS <br /> Credentials': X CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 433159 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Beaker <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DSL 4 <br /> Number, Stored Product, etc.) <br /> [Bucket Installation Type: X Direct Bury X Direct Bury X Direct Bury Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 14" 14" 14" <br /> Wait time between applying 0 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 140PM 140PM 140PM <br /> Initial Reading(R,): 13" 13" 13" <br /> Test End Time(TF): 240PM 240PM 240PM <br /> Final Reading(RF): 13" 13" 13" <br /> Test Duration(TF—Ti): l HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF—Rj): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Test Result: X Pass ❑Fail X Pass ❑Fail X Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed 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 <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 />