Laserfiche WebLink
SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of LIST 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 />Facility Name: Mobil/Tesoro Date of Testing: 02/23/17 <br />Facility address: 401 W. Kettleman Ln. Lodi, CA 95240 <br />Facility Contact: Elizabeth Okupe (209) 368-8787 "L.%0#L-1 V ED <br />Date Local Agency Was Notified of Testing: 2/8/17 <br />Name of Local Agency Inspector (if present during testing): Vicki McCartney <br />2. TESTING CONTRACTOR INFORMATION — - ®® k as AI -p, n I UE::A <br />Company Name: Service Station Systems... <br />Technician Conducting Test: Kris Bell <br />Credentialsi : ® CSLB Contractor ® ICC Service Tech. Q SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): License: 485184 ICC:5297793-UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />❑x Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: Measuring Tape <br />Equipment Resolution:1/16 in. <br />identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Pill EucKet <br />01 - Re u <br />2 I11 Bucket <br />02 - Prem <br />3 4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />❑x Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury ❑ Direct Bury <br />❑ Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: <br />13.00 in. <br />13.00 in. <br />Bucket Depth: <br />13.00 in. <br />13.25 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />10 min. <br />10 min. <br />Test Start Time (Ti ): <br />11:13am <br />11:13am <br />Initial Reading (Ri ): <br />13.000 in. <br />12.688 in. <br />Test End Time (TF }: <br />12:13pm <br />12:13pm <br />Final Reading (RF ): <br />13.000 in. <br />12.688 in. <br />Test Duration (TF -T1): <br />1.00 hr. <br />1.00 hr. <br />Change in Reading (RF - Ri ): <br />0.0000 in. <br />0.0000 in. <br />Pass/Fail Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />Test Result: <br />® Pass ❑ Fall <br />® Pass " ❑ Feil <br />❑ Pass❑'Fail ❑ Pass ❑ Fail <br />Comments: 87 & 91 failed replaced both fill caps, retested, passed <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />/ hereby certify that all the iqf9WwfiQn co lnad In this report is true, accurate,and In full compliance with legal requirements. <br />Technician's <br />Date: 02/23/17 <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 />