Laserfiche WebLink
Ell <br />0 Page _of <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 />TEST,TeG COIW,,,,4L.CTOW-PiV�OVILII,4LLT.too,,U <br />Company Name: TAIT ENVIRONMENTAL SERVICES <br />Technician Conducting Test: Dan Luck <br />Credentials': OCSLB Contractor 0 ICC Service Tech. El SWRCB Tank Tester 0 Other (Specify) <br />License Number(s): CSLB = 588098 ICC = 5240929 -UT <br />lei 10T.,wr4mF mlo <br />Test Method Used: <br />0 Hydrostatic <br />0 Vacuum <br />El Other <br />Test Equipment Used: INCON <br />Equipment Resolution: <br />.0006 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 605 <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />0 Direct Bury <br />OContained in Sump <br />El Direct Bury <br />[I Contained in Sump <br />0 Direct Bury <br />OContained in Sump <br />El Direct Bury <br />OContained in Sump <br />Bucket Diameter: <br />1211 <br />Bucket Depth. <br />131/4" <br />Wait time between applying <br />vacuum/water and start of test: <br />15 Min <br />Test Start Time (TO: <br />9:52 <br />10:07 <br />Initial Reading (RI): <br />4.0348 <br />4.0367 <br />Test End Time (TF): <br />10:07 <br />10:22 <br />Final Reading (RF): <br />4.0365 <br />4.0373 <br />Test Duration (TF— Tj): <br />15 Min <br />15 Min <br />Change in Reading (RF- RI): <br />.0016 <br />.0006 <br />Pass/Fail Threshold or <br />Criteria: <br />.002 <br />.002 <br />Test Result: <br />0 Pass []Fail <br />0 Pass 0 Fail <br />0 Pass 0 Fail <br />❑ Pass El Fail <br />Comments — (include information on repairs made prior to testing, and recommendedfollow-upforfailed tests) <br />Verified 5 gal capacity of bucket- NOTE: San Joaquin requires final lake test after <br />Concrete has been poured. <br />Technician's Signature:,,—,,�,�yt Date: <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. l4owever/ocal requirements <br />may be more stringent. <br />