Laserfiche WebLink
SWRCB,January 2006 <br /> Spill Bucket Testing Report Form JUN 2 0 2016 <br /> This form is intended for use by contractors performing annual testing of UST spill containment stAZt' 4A$1e completed form and <br /> printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the Meal regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: J & L MARKET I Date of Testing: 5/26/2016 <br /> Facility Address: 8125 S. ELDORADO ST. FRENCH CAMP, CA 95231 <br /> Facility Contact: EUGENIA Phone: <br /> Date Local Agency Was Notified of Testing:4/26/16 <br /> Name of Local Agency Inspector(tf present during testing): STACY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 211 Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ® Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ®ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 3 91 4 DIESEL <br /> Number, Stored Product, etc.) <br /> ®Direct Bury ❑ Direct Bury ® Direct Bury ®Direct Bury <br /> Bucket Installation Type: ❑Contained in E]Contained in <br /> [:1 Contained in Sump El Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 3/4 13 1/4 13 7/8 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 0925 0925 0925 <br /> Initial Reading(RI): 12 1/8 12 - 12 7/8 <br /> Test End Time(TF): 1025 1025 1025 <br /> Final Reading(RF): 12 1/8 12 - 12 7/8 <br /> Test Duration(TF—TI): HR HR HR HR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ❑ Pass ❑ Fail ® Pass ❑ Fail 1 ® Pass 1:1-F ail <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 /> 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 Date: 5-26-16 <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 />