COMPLIANCE INFO_2017-2018 - Laserfiche WebLink

Home Browse Search

E E SWRCB, January 2006 1. 111111,111111 i 1reTaTIM This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (if applicable) should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Valley Pacific Date of Testing: 01/17/18 Facility Address: 1501 West Charter Way, Stockton, CA 95206 Facility Contact: Mike Eliason I Phone: (209)993-8793 Date Local Agency Was Notified of Testing: 02/27/17 @ 2:25pm via email Name of Local Agency Inspector (ifpresent during testing): Cesar Ruvalcaba @ San Joaquin E.H.D. 2. TESTING CONTRACTOR INFORMATION Company Name: CGRS, Inc. Technician Conducting Test: RICHARD THOMAS Credentials': ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑ Other (Spec) License Number(s): 803616 (CSLB Contractor) -- 5254736 (ICC Service Tech.) -- 06-1672 (SWRCB Tank Tester) 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other (Spec) Test Equipment Used: Tape Measure Equipment Resolution: +or -1/16" ire eU�r, Identify Spill Bucket (By Tank Number, Stored Product, etc.) T -I 87 Fill T-2 Diesel Fill Bucket Installation Type: ® Direct Bury ❑ Contained in Sump ® Direct Bury ❑ Contained in Sump ❑ Direct Bury ❑ Contained in Sump ❑ Direct Bury ❑ Contained in Sump Bucket Diameter: 12" 12" Bucket Depth: 14" 13 1/2" Wait time between applying vacuum/water and start of test: 10min 10min Test Start Time (TI): 9:00am 9:00am Initial Reading (RI): 14" 1311211 Test End Time (TF): 10:00am 10:00am Final Reading (RF): 14" 13 1/2" Test Duration (TF — TI): 1 hr 1 hr Change in Reading (RF - RI): 0" 0" Pass/Fail Threshold or Criteria: No Loss No loss Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: A—�, Date: 01/17/18 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.