Laserfiche WebLink
SWRCB, January 2006 <br />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 <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: COUNTRY CLUB 76 1 Date of Testing: 1-30-12 <br />Facility Address: 2575 COUNTRY CLUB BLVD STOCKTON CA <br />Facility Contact: NICK Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): SAN JOAQUIN CO GARRETT <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 nd 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 / H2O <br />Identify Spill Bucket (By Tank 1 87 2 91 <br />Number, Stored Product, etc. <br />Equipment Resolution: 1/16 <br />3 DIE 4 <br />Bucket Installation Type: El Direct Bury <br />®Contained in Sump <br />El Direct Bury <br />®Contained in Sump <br />El Direct Bury <br />® Contained in <br />Sump <br />El Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: 11 <br />11 <br />11 <br />Bucket Depth: 13 <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): 900 <br />1000 <br />1100 <br />Initial Reading (RI): 13 <br />13 <br />13 <br />Test End Time (TF): 1000 <br />1100 <br />1200 <br />Final Reading (RF): 13 <br />13 <br />13 <br />Test Duration (TF — TI): 1 HOUR <br />1 HOUR <br />I HOUR <br />Change in Reading (RF - Rj): 0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: ® Pass ❑ Fail <br />® Pass ❑ Fail <br />Z Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />PHIL TITE BUCKETS <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:01-30-12 <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 />