Laserfiche WebLink
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 far• submittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name: CHEVRON 201761 Date of Testing : 1 /8/2019 <br /> Facility Address : 1103 S. MAIN ST. PERMIT NUMB . N-3315, MANTECA, CA 95337 <br /> Facility Contact: MGR - MARIE Phone: 209-825-0174 <br /> Date Local Agency Was Notified of Testing: 1 /4/2019 <br /> Name of Local Agency Inspector (if present during testing): ZUNA <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY INC. <br /> Technician Conducting Test: Jesus Saldivar <br /> Credentialsl : CSLB Contractor r ICC Service Tech. r- SWRCB Tank Tester Other (Specify) <br /> License Number(s) : <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By : Hydrostatic 170 ', Vacuum re Other <br /> Test Equipment Used : VACUUM TEST Equipment Resolution : 0. 1 gph <br /> Spill Box # Tank T2 Regular Spill Box # Tank T3 Regular Spill Box # Tank T I <br /> Identify Spill Bucket (By Tank 2 REGULAR - Fill I - Direct I REGULAR - Fill 1 - Direct Supreme SUPREME - Fill 1 Spill Box # <br /> Number, Stored Product, etc.) - Grade level in - Grade level in - Direct - Grade level in <br /> containment sump containment sump containment sump <br /> C` Direct Bury C Direct Bury r Direct Bury (` Direct Bury <br /> Bucket Installation Type : (; Contained in Sump r Contained in Sump 4: Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth : 12.00 12.00 12.00 <br /> Wait time between applying I min 1 min I min min <br /> vacuum/water and start of test <br /> Test Start Time (TI): 09:00:00 09:02:00 09:04:00 <br /> Initial Reading (RI): 30.00 in. H2O 30.00 in. H2O 30.00 in. H2O <br /> Test End Time(TF): 09:01 :00 09:03 :00 09:05 :00 <br /> Final Reading (RF): 30.00 in. H2O 30.00 in. H2O 28.00 in. H2O <br /> Test Duration(TF—TI): I min I min 1 min <br /> Change in Reading (RF—RI) : 0.00 in. H2O 0.00 hi. H2O -2. 00 in. H2O <br /> Pass/Fail Threshold or Criteria: +/- 4. 00 +/- 4.00 +/- 4.00 <br /> [TestResult: Fail Fail Fail <br /> Comments - (include information on repairs made prior to testing, and recommended follow-up for• failed tests) <br /> SPILL BUCKETS PASSED BUT DID NOT MEET THE FIVE GALLON CAPACITY. <br /> REPLACED FILL CAP ON 87 REG, SLAVE STP <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the inforniation contained in this report is true, accurate, and in fill compliance with legal requirements. <br /> Technician' s Signature : 4AW 4« Date : 1 /8/2019 <br /> t State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. <br /> i <br /> WO : 2339109 <br /> 4 <br /> E <br />