Laserfiche WebLink
E <br />E <br />Spill Bucket Testing Report Form <br />Thisform is intended for use by contractors performing annual testing (?/' UST spill containment structures. The completed form and <br />, <br />printouts front tests (if applicable), should be provided to theJacilit), owulerloperator.16r submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Arco AmPrn- Victor Rd Date of Testing: 9/14/2017 <br />0 0' <br />Cit- - Lodi <br />------------------ 0 9 <br />City: Lodi <br />Facility Address: 880 Victor Rd <br />Phone: 209-369 <br />ontact: Karan <br />Facility C <br />- <br />Date Local Agency Was Notified of Testing: Wednesday, August 30, 2017 <br />Name of Local Agency inspector (if present during testing): <br />R <br />2. TESTING CONTRAC4 UK ENVUMVIA I I'k111 <br />Company Name: BZ Service Station Maintenance <br />Technician Conducting Test: Rhorne Desbiens <br />Credentials': CSLB Contractor ICC Service Tech. WRCB Tank Tester ❑Other <br />License Number(s): 433159 <br />3. SPIIA, BUCKET TESTING INFORMATION <br />Test Method Used: <br />Hydrostatic <br />1 87 <br />Direct Bury <br />Fj Contained in Sum <br />lit, <br />13 1/2" <br />L -J Vacuum <br />2 DSL <br />Direct Bury <br />E] Contained in Sum <br />1101 <br />L -J <br />FEquipment Resolution: <br />�7-: <br />771 <br />3 91 <br />Direct Bury <br />E] Contained in Sum <br />III, <br />1/16" <br />4 <br />Direct Bury, <br />Contained in Sum <br />Test Equipment Used: Ruler <br />Identify Spill Bucket (Ay Tank <br />Number, Stored Product, etc) <br />Bucket Installation Type: <br />Bucket Diameter,* <br />13" <br />— <br />13 1/2" <br />Bucket Depth: <br />5min <br />5min <br />5min <br />Wait time between applying <br />vacuum/water and start of test: <br />10:20 <br />10:20 <br />11:57 <br />Test Start Time (Ti): <br />12" <br />11:20 <br />12" <br />lhr <br />12" <br />12" <br />Initial Reading (Rj): <br />11:20 <br />12:57 <br />Test End Time (TO: <br />12" <br />12" <br />Final Reading (RF): <br />— <br />1 h <br />1 h <br />Test Duration (TF - Ti): <br />0 <br />0 <br />Z Pass El Fail <br />0 <br />0 <br />Change in Reading (RF - Rj): <br />0 <br />Z Pass ❑ Fail <br />0 <br />Z pass E] Fail <br />... ., ", <br />M Pass ❑ Fail <br />fn- rdad tpvtq) <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />Commen-ts — (include infortnalion ott repairs fncjut�,Vt tur <br />91 Bucked failed, found leaking at Adaptor threads. Removed, cleaned. & reattached. Retested & PASSED. <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 may be more <br />stringent. <br />Monitoring Certification Test Report 4 of 4 <br />