Laserfiche WebLink
SWRCB,January 2006 <br /> Spill Bucket Testing Report Form AUG 0 1 20+5 <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures" <br /> tructure kted form and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the 1acai r al agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: KNIFE RIVER I Date of Testing: 7/12/16 <br /> Facility Address: 655 W.CLAY ST STOCKTON,CA <br /> Facility Contact: ROGER Phone: <br /> Date Local Agency Was Notified of Testing:6-27-16 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician: ®Ed Stearns ❑Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 5250492-UT 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ®ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 DIE 3 4 <br /> Number, Stored Product, etc.) <br /> ® Direct Bury ®Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: F1 Contained in F-1 Contained in <br /> El Contained in Sump ❑ Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 13 1/2 14 <br /> Wait time between applying _ <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 130 130 <br /> Initial Reading(Ri): 12 1/2 13 <br /> Test End Time(TF): 230 230 <br /> Final Reading(RF): 121/2 13 <br /> Test Duration(TF—Ti): IHR IHR <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑Fail Z Pass ❑Fail ❑ Pass ❑Fail ❑ Pass E] Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <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: &�fa_i_ Date:7/12/16 <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 />