Laserfiche WebLink
El <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: COUNTRYSIDE MARKET Date of Testing: 3/21/2016 <br />Facility Address: 14971 N. HWY 88 LODI, CA 95240 <br />Facility Contact: RUPI Phone: <br />Date Local Agency Was Notified of Testing :3/7/2016 <br />Name of Local Agency Inspector (f present during testing): ARIS C. <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ® Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -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 MEASURE, H2O Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank 1 87 <br />Number, Stored Product, etc.) <br />2 <br />3 91 <br />4 DIESEL <br />® Direct Bury <br />Bucket Installation Type: <br />❑Contained in Sump <br />❑ Direct Bury <br />❑Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />Sump <br />® Direct Bury <br />El Contained in <br />Sum <br />Bucket Diameter: 11 <br />11 <br />11 <br />Bucket Depth: 14 <br />11 <br />11 3/4 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): 0900 <br />0900 <br />0900 <br />Initial Reading (RI): 13 - <br />10 <br />10 3/4 <br />Test End Time (TF): 1000 <br />1000 <br />1000 <br />Final Reading (RF): 13 - <br />10 <br />10 3/4 <br />Test Duration (TF — Ti): HR <br />HR <br />HR <br />HR <br />Change in Reading (RF - RI): 0 <br />0 <br />0 <br />Pass/Fail Threshold or _ <br />Criteria: <br />Test Result:pass ❑ <br />Fail <br />❑ Pass ❑ Fail <br />1Z Paas ❑,; Fail <br />Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />L <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING -�.`v .� ® • .i� v : „ _ <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal rt mremafii. -V, <br />Technician's Signature Date: -3-21-16 <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 />