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 printout from <br /> tests(f applicable),should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: Shell Date of Testing: 10/14/2008 <br /> Facility Address: 3515 Navy Dr. Stockton CA 95203 <br /> Facility Contact: Gerald Lon Facili Phone: <br /> Date Local Agency Was Notified of Testing: 10/09/2008 <br /> Name of Local Agency Inspector if present during testing): Ray Von Flue <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Com an Name: TAIT ENVIRONMENTAL SERVICES <br /> Technician Conducting Test: Graham Stephen <br /> Credentials: ®CSLB Contractor ®ICC Service Tech ❑SWRCB Tank ❑Other(Specify) <br /> Tester <br /> License Number (s): A ASB HAZB C-10; 588098: 5240926-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used:Visual/Tae E ui ment Resolution: 1/16" <br /> Idents Spill Bucket(By Tank Number, 1 Slop Tank FiB 2 3 4 <br /> Stored Product,etc) <br /> ®Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type <br /> ❑Contained in Sump []Contained in Sump ❑Contained in Sump Contained in Sump <br /> Bucket Diameter inches 12.5" <br /> Bucket Depth inches 14.5" <br /> Wait Time between applying 15 Min. <br /> vacuum/water and start of test <br /> Test Start Time: 9:22am <br /> Initial Reading Ri): 14" <br /> Test End Time: 10:22am <br /> Final Reading 14" <br /> Test Duration: 1 Hr <br /> Chane in Reading Rf-Ri : 0 <br /> Pass/Fail Threshold or Criteria: 0 <br /> Test Result Pass <br /> Comments: Inspector Ray Von Flue apporoved testing spill bucket visually but would not sign. <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 x Date 10/14/2008 <br />