COMPLIANCE INFO_2009-2015 - Laserfiche WebLink

Home Browse Search

SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: BILLS 76 Date of Testing: 7-24-12 Facility Address: 633 E VICTOR LODI CA Facility Contact: BILL Phone: Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (f present during testing): ARIS 2. TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez 5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 Identify Spill Bucket (By Tank 1 87 2 89 3 91 4 Number, Stored Product, etc. ® Direct Bury ® Direct Bury ® Direct Bury ❑ Direct Bury Bucket Installation Type: El in Sump ❑Contained in Sump El Contained in ❑ Contained in Sump Sum Bucket Diameter: 11 11 11 Bucket Depth: 13.50 13.50 14 Wait time between applying -- -- _- vacuum/water and start of test: - Test Start Time (TI): 9 9 9 Initial Reading (RI): 13 12.50 13.50 Test End Time (TF): 10 10 10 Final Reading (RF): 13 12.50 13.50 Test Duration (TF — TI): 1 HR IHR 1 HR Change in Reading (RF - Rj): 0 0 0 Pass/Fail Threshold or 1/16 1/16 1/16 Criteria: Test Result: ® Pass ❑ Fail Z Pass ❑ Fail 2 Pass ❑ Fail ❑ Pass ❑Fail Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: Date 7-24-12 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.