Laserfiche WebLink
RECEIVED <br /> 10 9 ^ 2017 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form ENVIRONMENTAL HEALTH <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The complete cFnn�TMENT <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: ShellfTesoro Date of Testing:05/16/17 <br /> Facility Address: 2448 W. Kettleman Ln. Lodi, CA 95242 <br /> Facility Contact: Mary Morgan (209) 369-3124 <br /> Date Local Agency Was Notified of Testing: 4/26/17 <br /> Name of Local Agency Inspector (if present during testing): Vicky McCartney <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems... <br /> Technician Conducting Test: Randy Wilkerson <br /> Credentlalsi: ❑8 CSLB Contractor © ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:5258560-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> j Test Method Used: ® Hydrostatic ❑vacuum ❑ Other <br /> F <br /> fl�Test Equipment Used: Measuring Tape I Equipment Resolution://16 In. <br /> I Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 Fill Bucket 4 <br /> Number,Stored Product,etc.) 01 -Re u 02-Prem 03-Diesel <br /> ❑ <br /> Bucket Installation Type: Direct Bury E] Direct Bury ❑ Direct Bury [jDirect Bury <br /> ❑X Contained in Sump © Contained in Sump 0 Contained in Sump ❑ Contained in Sump <br /> BUCKet Diameter: 12.00 in. 12.00 in. 12.00 in. <br /> Bucket Depth: 14.00 in. 14.00 in. 14.00 in. <br /> Wait time between applying 5 min. 5 min. 5 min. <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 10:00am 10:00am 10:00am <br /> Initial Reading(Ri ): 13.250 in. 14.000 in. 14.000 in. <br /> l�Test End Time(TF): 11:00am 11:00am 11:OOam <br /> ,I Final Reading(R): 13.250 in. 14.000 in. 14.000 in. <br /> Test Duration(TF-T 1): 1.00 hr. 1.00 hr. 1.00 hr. <br /> Change in Reading(RF-RI): 0.0000 In. 0.0000 in. 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS <br /> T@St R@SUIt: © Pass ❑Fail ❑X Pass ❑Fail ❑X Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments: Include information on repairs made prior to testing, and recommended follow-up for failed tests. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> l hereby certify that all the InforrPation contained in this report is true,accurate,and in full compliance with legal requirements. <br /> ill <br /> Technician's Signature: W Date: 05!16/17 <br /> t 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 />