Laserfiche WebLink
SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of LIST spill containment structures. The completed form and <br /> printouts from tests(if applicable),should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: TRACY TRUCK AND AUTO STOP I Date of Testing: 4/15/08 <br /> Facility Address: 3940 N.Tracy Blvd Tracy Ca.95376 --FPhone: (209)832-5006 <br /> Facility Contact: Debbie Jutla <br /> Date Local Agency Was Notified of Testing: 3/25/08 <br /> Name of Local Agency Inspector(ii(present during testing): Michelle Henry <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company RELIABLE PETROLEUM SERVICES INC. <br /> Technician Conducting Test: Guadalupe Sanchez <br /> Credentials': X CSLB Contractor X ICC Service Tech. 0 SWRC13 Tank Tester 11 Other(Specify) <br /> License Number(s): 883706 5250451-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used: Standard Tape Measure Equipment Resolution: <br /> Identify Spill Bucket(By Tank Tl:87Unleaded T4:Diesel 2 East <br /> Number, Stored Product, etc. Fill Fill <br /> Bucket Installation Type: X Direct Bury X Direct Bury Direct Bury Direct Bury <br /> Contained in S!!Lnp Contained in Sump Contained in Sump Contained in Sump <br /> Bucket Diameter: 12" 1219 <br /> Bucket Depth: 13 7/8" 113/8" <br /> Wait time between applying 1 min. I min. <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1:00p.m 1:03p.m <br /> Initial Reading(Ri): 12" 8 9/16" <br /> Test End Time(TF): 2:05p.m 2:05p.m <br /> Final Reading(RF): 12" 8 9/16" <br /> Test Duration(TF—TO: 1hr. 5min. 1 hr.2min. <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or 1/16" 1/16" <br /> Criteria: <br /> Test Result: X Pass Fail X Pass Fail Pass Fail Pass Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> Replaced spill bucket on 87 Unleaded Fill & performed a witness test for both <br /> Shill buckets <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 Signa ft=,------,e5�- Date: 4/15/08 <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 />