Laserfiche WebLink
,, ;tECEi�� <br />e+ss-caw€�: cc�n�.Amae <br />Spill Bucket Testing Report Form L'-_ 2013 <br />This form is intended for use by contractors pei forming annual testing of UST spill containment stru�1 and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to y <br />1. FACILITY INFORMATION <br />Facility Name: Bonfare #35 Date of Testing: 12/10/2013 <br />Facility Address: 15 E. Grant Line Rd., Tracy, CA 95376 <br />Facility Contact: Russ I Phone: (209) 833-9619 <br />Date Local Agency Was Notified of Testing: 12/04/2013 <br />Name of Local Agency Inspector (fpresent during testing): Jeff Wong <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: ECO-CHEK Compliance <br />Technician Conducting Test: Nikola Zagorov <br />Credentials': ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 958763 A <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Tape Measure Equipment Resolution: 1/16 Inches <br />r „.,.. a ,,,... ,; <br />Identify Spill ,Bucket (By Tank I Super <br />Number, Stored Product, etc.) <br />2 Regular Syphon 3 Regular <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />® Contained in Sump <br />❑ Direct Bury ❑ Direct Bury <br />® Contained in Sump ® Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />12 Inches <br />12 Inches 12 Inches <br />Bucket Depth: <br />12 Inches <br />12 Inches 12 Inches <br />Wait time between applying <br />vacuum/water and start of test: <br />10 Minutes <br />10 Minutes 10 Minutes <br />Test Start Time (Tj): <br />10:00 AM <br />10:00 AM 10:00 AM <br />Initial Reading (Ri): <br />10 1/4 Inches <br />11 1/4 Inches 10 3/4 Inches <br />Test End Time (TF): <br />11:00 AM <br />11:00 AM 11:00 AM <br />Final Reading (RF): <br />10 1/4 Inches <br />11 1/4 Inches 10 3/4 Inches <br />Test Duration (TF— T,): <br />60 Minutes <br />60 Minutes 60 Minutes <br />Change in Reading (RF -RI): <br />0 Inches <br />0 Inches 0 Inches <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 Inches <br />1/16 Inches 1116 Inches <br />Test Result: ` <br />® Pass ❑ Fail <br />0 Pass'' ❑ Fail Z Pass ❑Fail <br />❑ Pass ❑ 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: rC>V Date: 12/10/2013 <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 />