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: RAINBOW AM/PM Date of Testing: 1-15-15 <br /> Facility Address: 130 S.WILSON WAY STOCKTON CA 95205 ILA <br /> Facility Contact: Parmajit Phone: 916-4163-4743 . <br /> Date Local Agency Was Notified of Testing:12-19-14 MAR <br /> Name of Local Agency Inspector(rf present during testing): " <br /> 2. TESTING CONTRACTOR INFORMATION ENVIRONMENTAL: <br /> _F407111 F <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo E Zane A.Nimmo ❑ David A.Winkler ❑ 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 MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket (By Tank 1 87 [2VS 3 91 4 DIESEL <br /> Number, Stored Product, etc.) <br /> ❑Direct Bury El Direct Bury <br /> Bucket Installation Type: ❑ Direct Bury ❑ Direct Bury E Contained in El Contained in <br /> ® Contained in Sump E Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: " <br /> Test Start Time(Ti): 1105 1105 1105 <br /> Initial Reading(Rj): 121/4 11 1/2 12 <br /> Test End Time(TF): 1205 1205 1205 <br /> Final Reading(RF): 121/4 11 1/2 12 <br /> Test Duration(TF—Tj): HR HR HR HR <br /> Change in Reading(RF-RI): O 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_follotiv-up.for failed 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 /> Technician's Signature e ~Date: 1-15-15 <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 />