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. FACILITY INFORMATION <br />Facility Name: Stockton <br />Date of Testing: 11/8/2021 <br />Facility Address: 1990 Piccoli Road , Stockton, CA 95215 <br />Facility Contact: Phone: - <br />Date Local Agency Was Notified of Testing: 11/8/2021 <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Brent Bowen <br />Credentials): fv— CSLB Contractor F ICC Service Tech. F7 SWRCB Tank Tester r— Other (Specify) <br />License Number(s): 74360 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used By: F Hydrostatic F Vacuum Other <br />Test Equipment Used: LAKE TEST Equipment Resolution: 0.0625 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Spill Box # Tank T1 dsl <br />Diesel - Fill I - Direct - <br />Grade level <br />Spill Box # <br />Spill Box # <br />Spill Box # <br />Bucket Installation Type: <br />C• Direct Bury <br />r Contained in Sump <br />C Direct Bury <br />r Contained in Sump <br />C Direct Bury <br />r Contained in Sump <br />f Direct Bury <br />r Contained in Sump <br />Bucket Diameter: <br />12.00 <br />Bucket Depth: <br />13.00 <br />Wait time between applying <br />vacuum/water and start of test <br />15 min <br />min <br />min <br />min <br />Test Start Time (Tl): <br />09:30:00 <br />Initial Reading (Rl): <br />12.00 in. <br />Test End Time(TF): <br />10:30:00 <br />Final Reading (RF): <br />12.00 in. <br />Test Duration(TF—Tl): <br />1 hr <br />Change in Reading (RF—Rl) : <br />0.00 in. <br />Pass/Fail Threshold or Criteria: <br />+/-0.00+/- <br />Test Result: <br />Pass <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECI INICIAN 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 <br />Date: 11/8/2021 <br />'State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. <br />WO: 2353287 <br />