Laserfiche WebLink
/ s <br /> Spill Bucket Testing Report Form ;. Eb <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form a <br /> v <br /> printoutsfrom tests(if applicable), should be provided to thefacili owner/oPeratorfor submittal to the local regulatory a enl 1® 11 2 <br /> 1.FACILITY INFORMATION 'E-MV! ON ME N11-1— <br /> �1-1— <br /> Facility Name:CHEVRON#99840 Date of Testing: 12/29/2015 <br /> Facility Address:4344 E WATERLOO RD @ 99,STOCKTON,CA 95215 <br /> Facility Contact:MANAGER Phone:209-931-2186 <br /> Date Local Agency Was Notified of Testing: 12/29/2015 <br /> Name of Local Agency Inspector(if present during testing):Cindy Yo <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Brent Bowen <br /> Credentialsi: W CSLB Contractor rv-1 ICC Service Tech. r*/– SWRCB Tank Tester r Other(Specify) <br /> License Number(s):743160 <br /> s <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: W Hydrostatic Vacuum Other <br /> Test Equipment Used:LAKE TEST Equipment Resolution:0.0625 in. <br /> Identify Spill Bucket(By Tank Spill Box#Tank T 1 Spill Box#Tank T2 REG <br /> Number, Stored Product, etc.) SUPREME-Fill 1-Direct- UNLEAD-Fill 1-Direct- Spill Box# Spill Box# <br /> Grade level Grade level <br /> C Direct Bury E Direct Bury r Direct Bury C Direct Bury <br /> Bucket Installation Type: r Contained in Sump r Contained in Sump r Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 <br /> Bucket Depth: 12.00 12.00 <br /> Wait time between applying 1 min 1 min min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 09:00:00 09:00:00 <br /> Initial Reading(Rl): 12.00 in. 11.75 in. <br /> Test End Time(TF): 10:00:00 10:00:00 <br /> Final Reading(RF): 12.00 in. 11.75 in. <br /> Test Duration(TF–T,): 1 min 1 min <br /> Change in Reading(RF–RI): 0.00 in. 0.00 in. <br /> Pass/Fail Threshold or Criteria: +/-0.25 +/-0.25 +/- +/- <br /> Test Result: Pass Pass <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> took water off site for recycling <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: -Alr— Date: 12/29/2015 <br /> 1State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent. <br /> WO:2324988 <br />