Laserfiche WebLink
lary 2006 <br />Spill Bucket Testing Report Form JUN'`°' 1 <br />r 9 <br />This form is intended for use by contractors performing annual testing of UST spill containment str'u�ig: eted farm 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: MONTEREY FUEKING SINCLAIR Date of Testing: 1-29-16 <br />Facility Address: 1001 E YOSEMITE AVE MANTECA CA <br />Facility Contact: aninash Singh Phone: <br />Date Local Agency Was Notified of Testing :1/19/16 <br />Name of Local Agency Inspector (rfpresent during testing): ELANA <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2nd 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 />u Credentials': ® ICC Service Tech. ® SWRCB Tank Tester II <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: h20 and <br />tape measure <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 91 <br />3 DSL <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />E] Contained in Sump <br />® Direct Bury <br />E] Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />Sump <br />El Direct Bury <br />F1 Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />14 <br />14 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TI): <br />914 <br />914 <br />914 <br />Initial Reading (RI): <br />13 <br />13.50 <br />13.50 <br />Test End Time (TF): <br />1014 <br />1014 <br />1014 <br />Final Reading (RF): <br />13 <br />13.50 <br />13.50 <br />Test Duration (TF — TI): <br />IHR <br />IHR <br />IHR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 <br />1/16 <br />777777-7— <br />Q,777,❑ Pits <br />Comments — (include information on repairs made prior to testing and recommended follow-up for failed tests) <br />®PW FLAPPERS <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 />T-6 <br />Technician's Signature: Date 1-29-16 <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 />