Laserfiche WebLink
0 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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Super Stop Market Date of Testing: 5-27-09 <br /> Facility Address: 290 N.Main,Manteca,CA 95336 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): Munny/Tweet <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: HMC-Henderson Maint Co <br /> Technician Conducting Test: Gavin Williams <br /> Credentials': ❑CSLB Contractor [X]ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 8016488-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [X]Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Water Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1-87 2-91 3-Diesel 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: X Direct Bury X Direct Bury X Direct Bury ❑Direct Bury <br /> Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 11" 11" 11" <br /> Bucket Depth: 14 14 12 <br /> Wait time between applying 1 hr 1 hr 1 hr <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 10:00a 10:00a 10:00a <br /> Initial Reading(RI): 13" 13" 93 4" <br /> Test End Time(TF): 11:00a 11:00a 11:00a <br /> Final Reading(RF): 13" 13" 9 3/4" <br /> Test Duration(TF—TI): 1 hr 1 hr 1 hr <br /> Change in Reading(RF-RI): None None None <br /> Pass/Fail Threshold or Pass Pass Pass <br /> Criteria: <br /> Test Result: X Pass ❑Fail X Pass ❑Fail X Pass ❑Fail ❑ 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 /> If <br /> Technician's Signature: r��L Date: <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />