COMPLIANCE INFO 2011 - 2017 - Laserfiche WebLink

Home Browse Search

SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: CHEROKEE LANE SERVICE Date of Testing: 10-31-11 Facility Address: 900 S. CHEROKEE LANE LODI, CA 95240 Facility Contact: Phone: Date Local Agency Was Notified of Testing :9/29/11 Name of Local Agency Inspector (if prescnl during lesting): ARIS CACAPIT 2. TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 416 2"' Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0 1 16 Technician Conducting Test: ❑ Lyle D. Nimmo ® Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez 5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ® Hydrostatic D Other Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" Identify Spill Bucket (liy Turok ,V7lmber, Stored Product, e1r.) 1 87 A 2 87 B 3 91 4 DIESEL Bucket Installation Type: ® Direct Bury El Contained in Sump ® Direct Bury F1 Contained in Sump ® Direct Bury El Contained in Sum ® Direct Bury El Contained in . Sum Bucket Diameter: 1 I 11 11 12 Bucket Depth: 14 1/4 12 1/4 14 3/4 11 Wait time between applying vacuum/water and start of test: Test Start Time (Ti): 1425 1425 1425 1425 Initial Reading (Ri): 13 1/2 11 1/4 13 7/8 10 7/8 Test End Time (TF): 1525 1525 1525 1525 Final Reading (RF): 13 1/2 11 1/4 13 7/8 10 7/8 Test Duration (TF — Tj): HR HR HR HR Change in Reading (RF- Ri): 0 0 0 0 Pass/Fail Threshold or Criteria: Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail Continents — (include information on repairs made prior to testing, and recommendedfollow-upforfailed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance -*� ith legal requirements. Technician's Signature: 6 Date: ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.