Laserfiche WebLink
RECF,.Nl, uary 2006 <br /> Spill Bucket Testing Report Form JUN 19 H18 <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 NgU"TAUgency. <br /> 1. FACILITY INFORMATION HEATH DEPARTMENT <br /> Facility Name: SYSTEM TRANSPORT I Date of Testing: 5/30/2018 <br /> Facility Address: 707 E. ROTH ROAD FRENCH CAW, CA 95231 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:4/24/2018 <br /> Name of Local Agency Inspector(if present during testing): STACY RIVERA <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: ® Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez ❑Ed Stearns <br /> #8883064-UT #8883059-UT #8883072-UT #8883080-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 DIESEL 2 2 3 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ❑Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: E] Contained in El Contained in <br /> ❑ Contained in Sump El Contained in Sump Sump Sum <br /> Bucket Diameter: 12 <br /> Bucket Depth: 10 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1405 <br /> Initial Reading(RI): 9 7/8 <br /> Test End Time(TF): 1505 <br /> Final Reading(RF): 9 7/8 <br /> Test Duration(TF—TI): HOUR <br /> Change in Reading(RF-RI): 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 follotiv-up.for.failed tests) <br /> MEASURED 5 GALLONS EXACTLY <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 /> OkAE� <br /> Technician's Signature: Date: 5/30/2018 <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 />