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 oivner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: MY MINI MART I Date of Testing: 06-25-15 <br /> Facility Address: 1756 NORTH WILSON WAY STOCKTON CA <br /> Facility Contact: SIGH Phone: 775-421-9978 <br /> Date Local Agency Was Notified of Testing:05-26-15 <br /> Name of Local Agency Inspector(if present during testing): SAN JOAQUIN CO CINDY <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 20d Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A.Winkler E Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: E ICC Service Tech. E SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: E Hydrostatic ❑ vacuum ❑ Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 4 <br /> Number, Stored Product, etc. <br /> ❑ Direct Bury ❑Direct Bury <br /> Bucket Installation Type: E Direct Bury E Direct Bury ❑Contained in El Contained in <br /> ❑Contained in Sump ❑ Contained in Sump SumpSum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 14 14 <br /> Wait time between applying _ _ <br /> vacuum/water and start of test: <br /> Test Start Time(Tt): 900 900 <br /> Initial Reading(R,): 13 1/2 13 <br /> Test End Time(TF): 1000 1000 <br /> Final Reading(RF): 13 1/2 13 <br /> Test Duration(TF—Tt): I HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or _ <br /> Criteria: <br /> Test Result: E Pass ❑Fail E Pass ❑ Fail El Pass El Fail El Pass El Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW BUCKETS <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the <br /> , iiinformation contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: 11 f� Date:06-25-15 <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 />