HomeMy WebLinkAboutGas Spill Bucket Results 3-17-164a Sou r n-\ E
SWRCB, January 2006
Spill Bucket Testing Report Form
Thisform is intendedfor use by contractors performing annual testing of UST spill containment structures. The completedform and
printoutsfrom tests (dapplicoble), should be provided to thefacility owner/operatorfor submittal to the local regulatory agency.
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 eontained in this report is true, accurate, and infull compliance with legal requirements.
Technician's Signature:Dare: 3 -tt-t6
' State laws and regulations do not currently require testing to be performed by a qualified conffactor. However, local requirements
may be more stringent.
1. FACILITYINFORMATION
Facility Name: ROSEDALE PLAZA GROUP Date of Testing: 3-17-16
Facility Address:785I ROSEDALEHWY
Facility Contact NOLLIE Phone: 661-588-0557
Date Local Agency Was Notified of Testing :
Name of Local Agency lnspector (if present duringtesting): KHRIS
2. TESTING CONTRACTOR II\TFORMATION
CompanyName:BSSRINC,
Technician Conducting Test:SALVADORNSANCHEZ
Credentialsr: fi CSLB Contractor E ICC Service Tech. D SWRCB Tank Tester n Other (Spectfi)
License Number(s):csLB#6728t2 I tCC TECH#5309490
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: E[ Hydrostatic ! Vacuum tr Other
Test Equipment Used:VISUAL Equipment Resolution:
Identifu Spill Bucket (By Tank
Number, Stored Product, etc.)
T1-87 SPILL
BUCKET 1
TI.87 SPILL
BUCKET2
T2.87 SIPIION T3.PREMIUM
Bucket Installation Type:n Direct Bury
ElContained in Sump
tr Direct Bury
EContained in Sump
tr DirectBury
E Contained in Sump
tr DirectBury
E Contained in Sump
Bucket Diameter:12"12"12"12"
Bucket Depth:16"16"t'7"t6"
Wait time between applying
vacuum/water and start of test:15 MIN,I5 MIN,15 MTN,15 MIN,
Test Start Time (Tr):l0:00 AM l0:00AM l0:00 AM l0:00 AM
Initial Reading (&):10"I0"l0'o 10"
Test End Time (Tp):1l:00AM I l:00 AM ll:00AM 1l:00 AM
Final Reading (R5):10"t0"10"10"
Test Duration (Tp - T1):I HOUR 1 HOUR T HOUR l HOTIR
Change in Reading (Rp-ft):0 0 0 0
Pass/Fa
Criteria
Threshold or 0.002"0.002 0.002"0.002"
?e*tRsuI*,XD. P*ss trFait ffii.:'Pess' 'E$'*il xE Pass.,,,f| FaiI XB''Fasr EFail