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01-13-09,01 ; 52 M;TOWN & COUNTRY CONTRACTORS ;916-636-9507 # 5/ 5 <br /> SWRCB,January 2006 <br /> Spill Bucket Vesting Report Farm <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures The completed jorrn and <br /> ? printoutsfrom tests(if applicable), should be provided to tlae facility owner/operator for submittal to the to a!regulatory agency. <br /> I <br /> 1. FACILITY INFORMATION <br /> Facility Name; COSTCO #7 031 1Date of Testing: 8112108 <br /> Facility Address: 2440 DANIELS RD., MANTECA, CA <br /> Facility Contact; LATHEM -TOWN &COUNTRY CONT. phone; <br /> Date Lovil Agency Was Notified of Testing, <br /> Name of Local Agency Inspector(if present during testing); <br /> 2. TESTING CONTRAC'T'OR INFORMATION <br /> Company Name: BZ Service Station Maintenance <br /> TechxniCi;it►Conducting Test: <br /> Credentials)'. X CSLB Contractor X JCC Service Tech, ❑SWRCB Tank Tester p Other(Specify) <br /> License Number(s): 433159 <br /> II 3. SPILL BUCKET TESTING INFORMATION <br /> P Test Method Used: X Hydrostatic ❑'Vacuum ❑Other <br /> i� Test Equipment Used: <br /> Equipment <br /> Resolution; <br /> ,1 11W <br /> Identifv Spill Bucket(Dy Tank 1 87A 2 87B 3 91 4 <br /> Number, Stared Produce, eta.) <br /> I]Direct Bury d Direct Bury Q Direct Bury ❑Direct Bury <br /> Bucket Installation Type; X Contained in Sump X Contained in Sump X Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12+' 12" 12" <br /> Bucket Depth: 15 15" 15" <br /> Wait tilre between applying 15 MINS 15 MINS 15 MINS <br /> ' vacuum/water and start of test: <br /> Test Start Time(Ti): 2:00 2:00 2:00 <br /> Initial Reading(R�): <br /> 14" 14+" 14'/2" <br /> Test End Timc(TF): 3:00 3;00 3:GO <br /> a Final Reading(RF): 14 <br /> 14++ 14'/z <br /> Test Muntion(TF-TI); I HR 1 HR 1 HR <br /> I Change in Reading(Rr-R4): 0 0 0 <br /> pass/Fail Threshold or 0 0 0 <br /> Criteria <br /> - <br /> [3 <br /> ®} <br /> T ';Ytesult;I, B <br /> est ❑F., H <br /> Comments- (include information on re irs trade prior to testing, and recommended follaw-u or ailed tests <br /> CERTIFICATION OF TEg ICIAN RESPONSIBLE FCONDUCTING THIS'TESTING <br /> I hereby certify float rrl!'Xlrt'brform ti ca rlacner!f this r yr u curate, and in full compliance with legal reguircmetats. <br /> oil <br /> Technician's Signa urer <br /> t Stm laws and regulations do not currently require testing tabc.pesl'ormed by a gpalificd contractor.However,local rtquirements <br /> MW be raore stringent. <br />