Laserfiche WebLink
07/23/2013 11:53 (20 )4854888 MaryAnn Henderson Page 517 <br /> RECEIVED <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form JUL 2 3 2013 <br /> This form is intended for use by contractors performing annual testing of UST spill containment structur¢ p�7 <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal ro the7ig f I AL. <br /> 1. FACILITY INFORMATION <br /> Facility Name: KWIK SERV I Date of Testing:6-28-13 <br /> Facility Address:824 E YOSEMPIE Manteca,Ca <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): SP S / NO INSP ON SITE <br /> 2. TESTING CONTRACTOR INF ION <br /> Company Name: Service Station Testing,be, <br /> Technician Conducting Test: Charles Ferrucci <br /> Credentials: 0 CSLB Contractor ICC ServiceTech 0 S WRCB Tank Testes 0 Other(Sped ) <br /> License Number(s): 5323096-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used: Water,Tape Measure,Stop Watch Equipment Resolution 1116" <br /> Identify Spill Bucket(By Tank I Reg Fill 2 Phis Fill 3 Premium Fill 4 <br /> Number,Stored Product,eta) <br /> Bucket Installation Type: irect Bury j&ectBury Bury d Direct Bury <br /> 0 Contained in Sump 0 Contained in Sump 0 Contained in Sump 0 Contained in Sum <br /> Bucket Diameter: 12 12 12 <br /> Bucket Depth: 12 12 12 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T): 0945 0945 0945 <br /> Initial Reading(Ril: 11.5 11.5 11.5 <br /> Test End Time(TF): 1045 1045 1045 <br /> Final Reading(RF): 11.5 11.5 11.5 <br /> Test Duration(TF—Til: 1 hr 1 hr 1 hr <br /> Change in Reading(RF-R): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Test Result: Pass 0 Fail Pass ❑Fail Pass 0 Fail 0 Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing,and recommended follow-up for failed tests) <br /> Water taken off site as test water <br /> CERTIFICATION OF CH IAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby cer*that all the" n red in this report is True,accurate,and in full compliance iunhGl`al requirements <br /> Technician's Sigaatore. Data: cd d <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 />