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 for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: COUNTRY MARKET I Date of Testing: JUN 22, 2009 <br />Facility Address: 1524 FRESNO AVENUE, STOCKTON, CA 95206 <br />Facility Contact: MIKE ELIASON I Phone: (209) 948-9412 <br />Date Local Agency Was Notified of Testing: JUN 9, 2009 <br />Name of Local Agency Inspector (tfpresent during testing): KASEY FOLEY <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br />Technician Conducting Test: MIKE LAWRENCE <br />Credentials': ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 803705 (CSLB Contractor) -- 1048103 -UT (ICC Service Tech.) -- 90-1200 (SWRCB Tank Tester) <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other (Spec) <br />Test Equipment Used: VISUAL Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />DIESEL FILL <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />11.50" <br />Bucket Depth: <br />14.00" <br />Wait time between applying <br />vacuum/water and start of test: <br />0 <br />Test Start Time (TI): <br />9:00 AM <br />Initial Reading (RI): <br />12.50" <br />Test End Time (TF): <br />10:00 AM <br />Final Reading (RF): <br />12.50" <br />Test Duration (TF — TI): <br />1 HR <br />Change in Reading (RF - Rt): <br />0 <br />Pass/Fail Threshold or Criteria: <br />Test Result: <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <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: �� ' =''�'` ``��%y Date: JUN 22, 2009 <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 />