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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1 _ FAC'TI.TTV INFORMATION Facility Name: BILLS 76 Date of Testing: 07-01-10 Facility Address: 633 E VICTOR RD LODI CA Facility Contact: RUPI Phone: Date Local Agency Was Notified of Testing :05-19-10 Name of Local Agency Inspector (fpresent during testing): ARIS 2. TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 4162 "d 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 A CPTT.T. RTTrWlWT TF.CTING INFORMATION thod Used: ® Hydrostatic ❑ Vacuum ❑ Other ipment Used: TAPE / H2O Equipment Resolution: 1/16 2 89 391 4 Spill Bucket (By Tank rNunStored Product, etc) i 1 87 nstallation Type: ® Direct Bury F-1Contained in Sump ® Direct Bury El❑Contained Contained in Sump ® Direct Bury in Sump El Direct Bury ❑ Contained in Sum Bucket Diameter: 11 11 11 Bucket Depth: 14 14 14 Wait time between applying vacuum/water and start of test: Test Start Time (Tj): 1045 1045 1045 Initial Reading (Ri): 125/8 12 1/2 13 Test End Time (TF): 1145 1145 1145 Final Reading (RF): 125/8 12 1/2 13 Test Duration (TF — TI): 1 HOUR 1 HOUR 1 HOUR Change in Reading (RF- Rj): 0 0 0 Pass/Fail Threshold or Criteria: - Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ® 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: State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.