Laserfiche WebLink
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: COUNTRY MARKETPLACE Date of Testing:317 Li <br /> Facility Address: 1789 W CHARTER WAY City:STOCKTON <br /> Facility Contact: HARP GILL Phone: (530)632-8758 , <br /> Date Local Agency Was Notified of Testing: 2127/17 <br /> Name of Local Agency Inspector(if present during testing): ROBERT/AARON VAn.,1v?e-%NA -- u <br /> PEf <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: BZ Service Station Maintenance <br /> Technician Conducting Test: JOHN Ll <br /> Credentials': CSLB Contractor ICC Service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number(s): 433159 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑vacuum ❑ Other <br /> Test Equipment Used: RULER Equipment Resolution: 1116" <br /> Identify Spill Bucket (By Tank 1 87LLj— 2 91 3 4 <br /> Number,Stored Product, etc.) ❑ Direct Bury <br /> ® Direct Bury ® Direct Bury Direct Bury <br /> Bucket installation Type: ❑ Contained in Sum F-1Contained in Sum F-1 Contained in Sum El Contained in Sum <br /> Bucket Diameter: 13„ 13" <br /> Bucket Depth: 14 112" 14 3f4" <br /> Wait time between applying 15 MIN 15 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(TO: 10:15 10:15 <br /> Initial Reading(Ri): <br /> 13 118" 14" <br /> Test End Time(TF): 11:15 11:15 <br /> Final Reading(RF): 13 118" 14" <br /> Test Duration(TF-Ti): <br /> IHR IHR <br /> Change in Reading(RF-Ri): <br /> 0 0 <br /> Pass/Fail Threshold or 0 0 <br /> Criteria: Pass ❑ ❑ Fail <br /> Test Result-. ® Pass Fail ® Pass ❑ Fail El Pas. Fail Pass <br /> Comments- (include in ormation on repairs made rior to testin , and in <br /> Ja!!vw-a� or ailed 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 /> Date:317117 <br /> Technician's Signature: <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more <br /> stringent. <br /> Monitoring Certification Test Report 4 oF4 <br />