Laserfiche WebLink
Spill Bucket Testing Report Form SWRCB, January 2006 <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 />FAsrr� r •-� +�a <br />Facility Name: Unocal Date of Testing: 12/20/12 <br />Facility Address: 2701 March Ln. Stockton, CA 95219 <br />Facility Contact: Darren Eppler (209) 473-7337 <br />Date Local Agency Was Notified of Testing: 12/13/12 <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Service Station Systems <br />Technician Conducting Test: Randy Wilkerson <br />Credentialst : ® CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): License: 485184 ICC:5268660-UT <br />Test Method Used: <br />® Hydrostatic <br />❑ vacuum <br />❑ Other <br />Test Equipment Used: Measuring Tape <br />Equipment Resolution:1/16 in. <br />a- v <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 Fill Bucket <br />01 Re u <br />2 Fill Bucket <br />02 Prem <br />3 Fill Bucket 4 <br />03 Diesel <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />[K Direct Bury E]Direct Bury <br />❑ Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: <br />12.00 in. <br />12.00 in. <br />12.00 in. <br />Bucket Depth: <br />14.00 in. <br />14.00 in. <br />14.00 in. <br />Wait time between applying <br />vacuum/Water and start of test: <br />5 min. <br />5 min. <br />5 min. <br />Test Start Time (Ti ): <br />10:00am <br />10:00arn <br />10:00am <br />Initial Reading (R, ): <br />13.000 in. <br />13.250 in. <br />13.000 in. <br />Test End Time (TF ): <br />11:00am <br />11:00ant <br />11:00am <br />Final Reading (RF }: <br />13.000 in. <br />13.250 in. <br />13.000 in. <br />Test Duration (TF - T, ): <br />1.00 hr. <br />1.00 hr. <br />1.00 hr. <br />Change in Reading (RF - R, }: <br />0.0000 in. <br />0.0000 in. <br />0.0000 in. <br />Pass/Fail Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />`It i#tt <br />s:. IFS it ,II N", <br />Comments: Include information on repairs made prior to testing, and recommended follow-up for failed tests. <br />®_t_ 7 'A 1)n In <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 /n full compliance with legal requirements. <br />Technician's Signature: ji Date: 12/20/12 <br />t 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 />