Laserfiche WebLink
e ' <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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name : ABC PETROLEUM — TRACY TEXACO Date of Testing : 094048 <br /> Facility Address : 2375 TRACY BLVD . TRACY, CA 95376 <br /> Facility Contact: HAKAM Phone : 209- 835 -5358 <br /> Date Local Agency Was Notified of Testing: 084248 <br /> Name of Local Agency Inspector (tf present during testing) : SAN JOAQUIN CO ZUNA <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: ❑ 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 DIE 2 91 3 WASTE OIL 487 <br /> Number, Stored Product, etc. <br /> ® Direct Bury ® Direct Bury ® Direct Bury ® Direct Bury <br /> Bucket Installation Type : ❑ Contained in ❑ Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump SumpSum <br /> Bucket Diameter: 11 11 11 11 <br /> Bucket Depth: 13 13 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test : <br /> Test Start Time (Ti) : 1320 1320 1320 1320 <br /> Initial Reading (RI) : 12 12 13 13 <br /> Test End Time (TF) : 1420 1420 1420 1420 <br /> Final Reading (RF) : 12 12 13 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 <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 /> MAR 14 20M <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 re uirements. <br /> Eta \/IRONMENTAL HMLTVA <br /> DFP/lRTMENIT <br /> Technician' s Signature: Date : 094048 <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 />