Laserfiche WebLink
1 <br /> RUQ�; January 2006 <br /> Spill Bucket Testing Report Form MAY 112016 <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 regulad u . <br /> 1.FACILITY INFORMATION <br /> Facility Name:7-ELEVEN#32262,MKT 2368(N-3940-1 Date of Testing: 5/5/2016 <br /> Facility Address:2360 W GRANTLINE I-205 OFF RAMP,TRACY,CA 95376 <br /> Facility Contact:CHANDRA Phone:209-830-9917 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jesus Saldivar <br /> Credentials): r---", CSLB Contractor Pl-' ICC Service Tech. r-1 SWRCB Tank Tester Other(Specify) <br /> License Number(s): <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: Hydrostatic �? Vacuum Other <br /> Test Equipment Used: Equipment Resolution: <br /> Spill Box#Tank T6 PUL Spill Box#Tank T5 MUL Spill Box#Tank T4 RUL <br /> Identify Spill Bucket(By Tank PREMIUM-Fill 1 -Direct- MIDGRADE-Fill 1-Direct REG UNLEAD-Fill I- Spill Box# <br /> Number, Stored Product, etc.) Grade level in containment -Grade level in Direct-Grade level in <br /> sump containment sump containment sump <br /> f' Direct Bury r Direct Bury r Direct Bury r Direct Bury <br /> Bucket Installation Type: to" Contained in Sump C Contained in Sump C Contained in Sump r Contained in Sump <br /> Bucket Diameter: 13.00 13.00 13.00 <br /> Bucket Depth: 15.00 15.00 15.00 <br /> Wait time between applying <br /> 5 min 5 min 5 min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 09:00:00 09:00:00 09:00:00 <br /> Initial Reading(Rl): 13.00 in.H2O 12.00 in.H2O 14.00 in.H2O <br /> Test End Time(TF): 10:00:00 10:00:00 10:00:00 <br /> Final Reading(RF): 13.00 in.H2O 12.00 in.H2O 14.00 in.H2O <br /> Test Duration(TF-TI): 1 hr I hr 1 hr <br /> Change in Reading(RF-RI): 0.00 in.H2O 0.00 in.H2O 0.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-0.00 +/-0.00 +/-0.00 +/- <br /> Test Result: Pass Pass Pass <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> none.. <br /> all tasks completed.. <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: 11 Date: 5/5/2016 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent. <br /> WO:2327818 <br />