Laserfiche WebLink
AMOVicU Fanuary 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: VALLEY PACIFIC CARDLOCK11152 Date of Testing: 3/23/2016 <br /> Facility Address: 930 E VICTOR ROAD,LODI, CA 95240 <br /> Facility Contact: MIKEELIASON Phone: (209)948-9412 <br /> Date Local Agency Was Notified of Testing: 319116 <br /> Name of Local Agency Inspector(fpresent during testing): SAN JOAQUIN COUNTY INSPECTOR <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br /> Technician Conducting Test: RICHARD THOMAS <br /> Credentials: ®CSLB Contractor ❑ICC Service Tech. ❑S WRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 803705(CSLB Contractor)-5254736-UT(/CC Service Tech.)-06-1672(SWRCB Tank Tester) <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: M Hydrostatic ❑Vacuum ❑Other(Spec) <br /> Test Equipment Used: VISUAL-TAPE MEASURE Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank <br /> Number,Stored Product, eta) T6 87 FILL T6 87 FILL <br /> Bucket Installation Type: ®Direct Bury M Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12" 12" <br /> Bucket Depth: 11.25" 11.25" <br /> Wait time between applying 10 MIN 10 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 12:55 12:55 <br /> Initial Reading(R,): 9.76" 9.75" <br /> Test End Time(Tr): 1:55 1:55 <br /> Final Reading(RF): 9.75" 9.75" <br /> Test Duration(Tr-TO; 1 HR 1 HR <br /> Change in Reading(RF-R,): 0 0 <br /> Pass/Fail Threshold or Criteria: NO LOSS NO LOSS NO LOSS NO LOSS <br /> 'fest Result: ® Pass ❑Fail ® Pass 0 Fail ❑ Pass ❑Fail [] Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-upforfailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the At __ <br /> information contained in this report Is true,accurate,and in full compliance with legal requirements. <br /> -- <br /> Technician's Signature: l- d v� Date: 3/23/2016 <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 />