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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: QUICK&EASY IDate 0 I <br /> Facility Address: 824 YOSEMITE AVE MANTECA CA <br /> Facility Contact: Kahn Phone: <br /> Date Local Agency Was Notified of Testing:6-26-14 JUL <br /> Name of Local Agency Inspector(fpresent during testing): ELENA ��tt��11 <br /> V1RON <br /> 2.TESTING CONTRACTOR INFORMATION' TMENT <br /> Company Name: AFFORDA TEST 416 2"a 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: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket (By Tank 1 87 2 91 3 89 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: <br /> ® Direct Bury ® Direct Bury ® Direct Bury ❑Direct Bury <br /> El Contained in Sump ❑ El Contained in El Contained inContained in Sump Sump Sum <br /> Bucket Diameter: 11 11 1 I <br /> Bucket Depth: 14 14 15 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 1215 1215 1215 <br /> Initial Reading(Rt): 13 13.50 14 <br /> Test End Time(TF): 115 115 115 <br /> Final Reading(RF): 13 13.50 14 <br /> Test Duration(TF—Tj): IHR IHR IHR <br /> Change in Reading(RF-R1): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <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 /> OPW <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 6-30-2014 <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 />