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 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 /> Facili Name: Shell I Date of Testing: 7-9-09 <br /> Facility Address: 2494 Fremont St Stockton 95205 <br /> Facility Contact: Mike Phone: 209 941-8743 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local A enc Ins br(i resent durim testing2: <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: <br /> Credentials': U CSLB Contractor U ICC Service Tech. U SWRCB Tank Tester U Other(�S)eco� <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: U Hydrostatic U Vacuum U Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number.Stored Product etc.2 <br /> Bucket Installation Type: U Direct Bury U Direct Bury U Direct Bury U Direct Bury <br /> LJ Contained in Sump U Contained in Sum p U Contained in Sum U Contained in SMR <br /> Bucket Diameter: <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T 0: <br /> Initial Reading(RI): <br /> Test End Time(T F): <br /> Final Reading(RF): <br /> Test Duration(T F-TI): <br /> Change in Reading(RF- <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: 0 Pass 0 Fail 0 Pass 0 Fail 0 Pass 0 Fail 0 Pass 0 Fail <br /> Comments— include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> Found small amount 61 water in 87 Fill an 9 1 Fill. Removed Waffe-r. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information cot amed in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: t Date: 7-9-09 <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 />