Laserfiche WebLink
1 1 • • <br /> 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: S.R.H. US GAS IFDatc of Testing: 5-20-13 <br /> Facility Address: 749 E. CHARTER WAY, STOCKTON, CA 95205 <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing:4/23/13 <br /> Name of Local Agency Inspector(r(present during testing): STACY <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2vd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ® Zane A.Nimmo ❑ 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 /> ldent4 Spill Bucket(By Tank 1 87 2 3 91 4 DIESEL <br /> Number, Stored Product, etc.) <br /> ® <br /> Bucket Installation Type: Direct Bury ❑Direct Bury ®Direct Bury ® Direct Bury El in Sump ❑ E]Contained in ❑ Contained inContained in Sump Sum Sum <br /> Bucket Diameter: I I I I 11 <br /> Bucket Depth: 13 12 1/2 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1038 1038 1038 <br /> Initial Reading(Rj): 12-- 11 1/2 12-- <br /> Test End Time(TF): 1138 1138 1138 <br /> Final Reading(RF): 12-- 11 1/2 12-- <br /> Test Duration(TF—Tj): HR HR HR <br /> Change in Reading(RF-RO: <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 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 Date: 5-20-13 <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 /> I <br />