Laserfiche WebLink
SWRCB, January 2006 <br />9. Sell Bucket Testing Repol , orm <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 />FacilityName: 7 -ELEVEN #19976, MKT 2237 <br />DateofTesting: 01/02/2008 <br />Facility Address: 1399 N. MAIN ST. Q NORTHGATE, MANTECA, CA, 95336 <br />Facility Contact: BEN <br />Phone: (2 0 9) 239-3252 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY , INC. <br />Technician Conducting Test: HEATH MCEVER <br />Credentials : <br />[] <br />CSLB Contractor <br />E <br />ICC Service Tech. [] SWRCB Tank Tester <br />E <br />Other (Specify) SERVICE TECH <br />License Number: 5236756 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: Hydrostatic Vacuum F-1 Other <br />Test Equipment Used: WATER <br />Equipment Resolution: INCHES <br />Identify Spill Bucket(By Tank <br />Number, Stored Product, etc) <br />1 4 REG FILL <br />2 5 PRE FILL <br />3 <br />4 <br />Bucket Installation Type: <br />Direct Bury <br />XD Contained in Sump <br />E]Direct Bury <br />XD Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and starting test: <br />Test Start Time (TI ): <br />1430 <br />1430 <br />Initial Reading (RI ): <br />11 3/4 <br />11 3/4 <br />Test End Time (TF ): <br />1530 <br />1530 <br />Final Reading (RF ): <br />11 3/4 <br />11 3/4 <br />Test Duration: <br />1 HR <br />1 HR <br />Change in Reading (R F - RI ): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />Test Result: <br />1XI Pass 1:1 Fail <br />E Pass 1:1 Fair <br />❑ Pass 1:1 Fail <br />❑ 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 />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 <br />01/02/2008 <br />I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />