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: COUNTRY MART&FOOD Date of Testing: 04-09-18 <br /> Facility Address: 34243 S CHRISTMAN RD. TRACY,CA 95376 <br /> ,r <br /> Facility Contact: SAHDU Phone: 209-832-8642 <br /> Date Local Agency Was Notified ofTesting:02-28-18 P R 2" <br /> Name of Local Agency Inspector(fpresent during testing): SAN JOAQUIN CO NETY <br /> 2. TESTING CONTRACTOR INFORMATION ENVIRONADTNA MENTAL <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Ed Stearns ❑ Zane A.Nimmo ❑ David A.Winkler ® Felix G.Ramirez <br /> 8883080-UT 8883064-UT 8883059-UT 8883072-UT <br /> Credentials': ®ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket (By Tank 1 87 2 91 3 DIE [��7 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury ®Direct Bury ®Direct Bury <br /> Bucket Installation Type: El Contained in El Contained in <br /> ❑ Contained in Sump El Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 11 <br /> Bucket Depth: 13 13 14 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1000 1000 1000 1000 <br /> Initial Reading(RI): 12 12 121/2 13 <br /> Test End Time(TF): 1100 1100 1100 1100 <br /> Final Reading(RF): 12 12 121/2 13 <br /> Test Duration(TF—Ti): 1 HOUR 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Test Result: ® Pass [:]Fail ® Pass ❑ Fail ® Pass ❑Fail ® Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW BUCKETS <br /> ALL BUCKETS TESTED FOR 5 GALLONS = PASS <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:04-09-18 <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 />