HomeMy WebLinkAboutSB RETEST 2015SWRCB, January 2006
Spill Bucket Testing Report Form
This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and
printouts from tests (if applicable), should be provided to the facility owner/operator forsubmittal to the local regulatory agency.
1.FACILITY INFORMATION
Facility Name:Date of Testing:
Facility Address:
Facility Contact:Phone:
Date Local Agency Was Notified of Testing :
Name of Local Agency Inspector (if present during testing):
2.TESTING CONTRACTOR INFORMATION
Company Name:Confidence UST Services, Inc.
Technician Conducting Test:
Credentials1:CSLB Contractor ICC Service Tech. SWRCB Tank Tester Other (Specify)
License Number(s):CSLB#804904 ICC#
3.SPILL BUCKET TESTING INFORMATION
Test Method Used:Hydrostatic Vacuum Other
Test Equipment Used:Lake TestEquipment Resolution:0.0625”
Identify Spill Bucket (By Tank
Number, Stored Product, etc.)
1234
Bucket Installation Type: Direct Bury
Contained in Sump
Direct Bury
Contained in Sump
Direct Bury
Contained in Sump
Direct Bury
Contained in Sump
Bucket Diameter:
Bucket Depth:
Wait time between applying
vacuum/water and start of test:
Test Start Time (TI):
Initial Reading (RI):
Test End Time (TF):
Final Reading (RF):
Test Duration (TF – TI):
Change in Reading (RF -RI):
Pass/Fail Threshold or
Criteria:
Test Result: Pass Fail Pass Fail Pass Fail Pass Fail
Comments –(include information on repairs made prior to testing, and recommended follow-up for failed tests)
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements.
Technician’s Signature:________________________________________________ Date:_________
1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements
may be more stringent.
(661)327-5008
09/042015
KrisKarns
Super
12.00"
12.50"
5min.
1:00pm
11.25"
2:00pm
11.25"
1hour
0.00"
0.0625"
Ming Chevron 09/04/2015
6601 Ming Avenue, Bakersfield, CA 93309
Tim Sullivan
Dustin Reese
8216722-UT
09/09/2015