Laserfiche WebLink
SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing MUST spill containment structures. The completed.1brin and <br /> printoutsfromtests(ij'applicable), should be provided to the facility ownerloperator.for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: H& M KWIK SERVE BW98 Date of Testing: 8/30/2017 <br /> Facility Address: 2501 E.JACKSON <br /> Facility Contact: MODESTO Phone: 209-838-31971 <br /> Date Local Agency Was Notified of Testing: <br /> LName of Local Agency Inspector(if present during tesflngl: <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name L.C.SERVICES <br /> Technician Conducting Test: PETER WESTBROOK <br /> Credentials': El CSLB Contractor X ICC Service Tech. 0 SWRCB-Tank Tester Fj Other(Specify) <br /> License N u m b e r(s):8 71'1 623 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X--Hydrostatic 110 Vacuum 1-1 Other <br /> Test Equipment Used: WATER Equipment Resolution:TAP <br /> Identify Spill Bucket (,qy Tank 1 87 FILL 2 91 FILL 3 DIESEL FILL 4 <br /> Number, Stared Product, etc.2_ <br /> Bucket inst--flanon, Direct Bury <br /> Typc: X Direct Bury X Direct Bury X Direct Bury I - <br /> Contained in Sump Contained in Sump Contained in Sump i..]Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 14" 14" 14" <br /> Wait time between applying 30-MIN 30-MIN 30-MIN <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:OOAM 9:OOAM 9:OOAM <br /> Initial Reading(Rj): 14" 14" 15" <br /> Test End Time(TF): .10:00AM 10:OOAM I O:OOAM <br /> Final Reading(RF): 14" 4" 2" <br /> Test Duration(TF—T°): 1-HR I-HR I-HR <br /> Change in Reading(RF-R,): NONE NONE NONE <br /> Pass/Fai!Threshold or PASS FAILED FAILED <br /> Criteria: I <br /> [lest Result X Pass Fail X Pass Fail X Pass Fail 0 Pass []Fail <br /> Comments—(include information on repairs made Et for to testing, and recommended follolv-up.forfailed tests) <br /> DSL A 4D 91 FAILED WILL NEED TO REIURN FOR REPAIRS <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby cerqy Iltat all the information coulahzed ft;this report is trite,accurate,and hi full compliance with legal requirements. <br /> Technician's Signature: --c Date: 7 <br /> p� V 4A47y <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 />