Laserfiche WebLink
SWRCB, January 2006 <br />Spill Bucket Testing Report Form <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 owner/operator for submittal to the local regulatory agency. <br />1. FACIIATV INFORMATION <br />Facility Name: FLAG CITY SHELL Date of Testing: 3-8-2016 <br />Facility Address: 6437 W BANNER RD LODI CA <br />Facility Contact: Rupi Padda Phone: 334-3214 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (f present during aris <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 Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez <br />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: H2O & <br />TAPE MEASURE <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank2 <br />Number, Stored Product, etc.) <br />Yn <br />91 <br />3 DSL <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sump <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />12.50 <br />12.50 <br />12.50 <br />Wait time between applying <br />vacuum/water and start of test: <br />NA <br />NA <br />NA <br />NA <br />Test Start Time (Ti): <br />11 <br />11 <br />l l <br />Initial Reading (Ri): <br />12 <br />12 <br />11.25 <br />Test End Time (TF): <br />12 <br />12 <br />12 <br />Final Reading (RF): <br />12 <br />12 <br />11.25 <br />Test Duration (TF — Tj): <br />1 HR <br />1 HR <br />1 HR <br />Change in Reading (RF - Rz): <br />0 <br />0 <br />O <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 <br />1/16 <br />it y7'''S ✓ `/ — <br />�1k± �l✓i <br /><, a <br />✓ y� <br />✓ T'ss D fail .t✓, <br />litiNri " r <br />�i -8 F 9 Il <br />r' <br />i <br />71l`i fi <br />Piss✓ <br />✓ <br />FaYI <br />✓ <br />e tat r r4`iVA 06 <br />t 15 <br />✓Ps,{ ,f '1, <br />Comments — (include information on repairs made prior to testing, and <br />AR 2 5 2016 <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING ENVIRONMENTAL <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. wER $ -1-w n PA Tk4EK!T <br />Technician's Signature: Date: 3-08-2016 <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 />