Laserfiche WebLink
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 farm and <br />printouts from tests (if applicable), should be provided to thefacility owner/operator for submittal to the local regulatory agency. <br />.. ► � t i(/i111Ii7ril <br />Facility Name: TRACY VALERO Date of Testing: 10-07-13 <br />Facility Address: 2375 TRACY BLVD TRACY CA <br />Facility Contact: HAKAM Phone: 209-835-5358 <br />Date Local Agency Was Notified of Testing :09-03-13 <br />Name of Local Agency Inspector (fpresent during testing): SAN JOAQUIN CO Thuy <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ® David A. Winkler Z Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials: Z ICC Service Tech. [ SWRCB Tank Tester <br />r L i t 4' i7�1 <br />Test Method Used: Z Hydrostatic ❑ Vacuum Other <br />Test Equipment Used: TAPE / H2O Equipment Resolution: 1/16 <br />Identify Spill Bucket (lay Tank <br />Number, Stored Product, etc. <br />1 89 <br />2 91 <br />3 WASTE OIL <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />El Contained in Sump <br />® Direct Bury <br />❑Contained in Sump <br />®Direct Bury <br />El Contained in <br />Sump <br />Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />i 1 <br />11 <br />I 1 <br />Bucket Depth: <br />13 <br />13 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />- <br />Test Start Time (Ti): <br />1300 <br />1300 <br />1300 <br />Initial Reading (Ri): <br />12 <br />12 <br />12 <br />Test End Time (TF): <br />1400 <br />1400 <br />1400 <br />Final Reading (RF): <br />12 <br />12 <br />12 <br />Test Duration (TF—Tl): <br />1 HOUR <br />I HOUR <br />1 HOUR <br />Change in Reading (RF - R{): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />_ <br />Test Result: <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />®Pass ❑ Fall <br />❑ Pass ❑ Fait <br />Comments — (include information on repairs made prior to testing, and recommended follotituEnr-LTYedtests) <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: <br />"r Date: 10-07-13 <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 />