Laserfiche WebLink
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 printouts <br /> from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: BP#6020 Date of Testing: 02/20/09 <br /> Facility Address: 1711 E. Yosemite Manteca Ca <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: 02/17/09 <br /> Name of Local Agency Inspector(if present during testing): Munaippa Naidu <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: B&T Service Station Contractor <br /> Technician Conducting Test: Aaron Shultz <br /> Credentials: x CSLB Contractor x ICC Service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number(s): 902034 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic Vacuum Cher <br /> Test Equipment Used: yt' v Equipment Resolution: <br /> Identify Spill Bucket(By Tank 187 289 391 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> X Contained in Sump X Contained in Sump X Contained in Sump Contained in Sum <br /> Bucket Diameter: er 1 2 r/ (2 r/ <br /> Bucket Depth: (-Z Z Z!f <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T,): >— 06> P rn <br /> Initial Reading(Rt): I t <br /> Test End Time(Tr): e' y', -!d y.,, Z.L ©ems Wl <br /> Final Reading(RF): ! ( Q I� ILI <br /> Test Duration(T,-–T,): pv(` (- p U r <br /> Change in Reading(RF-R,): << C( <br /> Pass/Fail Threshold or Criteria: <br /> Test Result: a Fail a Fail ago Fail I Pass Fail <br /> Comments–(include information on repairs made prior to Testing,and recommended follow-up for failed tests) <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may <br /> be more stringent. <br /> 5 <br />