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(ifopplicable), should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: QUICKI KLEEN Date of Testing: 10-09-17 <br /> Facility Address: 707 YOSEMITE AVE MANTECA CA 95336 <br /> Facility Contact: FRANCENE Phone: <br /> Date Local Agency Was Notified of Testing:9-20-17 <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Ed Sterns ❑ Zane A.Nimmo ❑ David A.Winkler E Felix G.Ramirez <br /> 814188-UT 8211269-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/H2O Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 87 2 87 3 DIESEL 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: E]Direct Bury Contained in Sum ❑Direct Bury E]Direct Bury F1 Direct Bury <br /> ® E Contained in El Contained in <br /> Sump E Contained in Sump Sump Sum <br /> Bucket Diameter: 11 I 1 11 <br /> Bucket Depth: 17 17 16 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 900 900 900 <br /> Initial Reading(Ri): 16 16 15 <br /> Test End Time(TF): 1000 1000 1000 <br /> Final Reading(RF): 16 16 15 <br /> Test Duration(TF—Tt): I HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: E Pass ❑ Fail E Pass ❑Fail E Pass ❑Fail ❑ Pass ❑Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW BUCKETS <br /> ALL BUCKETS HOLD OVER 5 GALLONS <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:ef� Date:10-09-17 <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 />