Laserfiche WebLink
JECENVEDD <br />2009swRCB, January 2006 <br />Spill Bucket Testing Report Fofflft ON MENT HEALTH <br />This firm is intended for use by contractors performing annual testing of UST spill contai . CF&- completed form and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Unified Grocers Date of Testing: 2-18-09 <br />Facility Address: 1990 Piccoli Rd. Stockton, Ca. <br />Facility Contact: Fleet Manager Phone: 209-931-1990 <br />Date Local Agency Was Notified of Testing :2-13-09 <br />Name of Local Agency Inspector (f present during testing): Jeff Wong <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: X Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />ldiesel <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />X Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in S!!Tp <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />'12" <br />Bucket Depth: _ _ <br />16" <br />Wait time between applying <br />vacuum/water and start of test: <br />30 min. <br />Test Start Time (TI): <br />0900 <br />Initial Reading (RI): <br />15.5" (full) <br />Test End Time (TF): <br />10:00 <br />Final Reading (RF): <br />15.5 (full) <br />Test Duration (TF — TI): <br />1 hour <br />Change in Reading (RF - RI): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />Test Result. <br />Fail <br />❑_ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATIO OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby cert that all the in r tion contained ' this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: Date: <br />-18 <br />' State laws and regulations do not currently require testing to be perfo ed by a qualified contractor. However, local requirements <br />