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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: LOVES TRUCK CENTER Datc of Testing: 8-15-12 <br /> Facility Address: 1533 COLONY RD. RIPON, CA 95366 <br /> Facility Contact: KIM&KEVIN Phone: <br /> Date Local Agency Was Notified of Testin.- <br /> Name of Local Agency Inspector(ifpresent during testing): MUNI& STACY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 d Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D. . Zane A.Nimmo X❑ David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-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 /> Identity Spill Bucket (iii 'lank 187 2 87 SLAVE 3 91 4 <br /> umber, Stored Product, etc.) <br /> ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ®Contained in El Contained in <br /> ®Contained in Sump ®Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 I 1 <br /> Bucket Depth: 14 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 9 9 9 <br /> Initial Reading(Rt): 13 12 12 <br /> Test End Time(TF): 10 10 10 <br /> Final Reading(RF): 9 12 12 <br /> Test Duration(TF—Tj): 11R HR HR I IR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: 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 /> To be reaaired and retested <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 is ith legal requirements. <br /> Technician's Signature: Date: 8-15-12 <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 V "_ E. <br />