HomeMy WebLinkAbout2023 Baker Spill BucketSpill 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 for submittal to the local regulatory agency.
FACILITY INFORMATION
Facility Name:
FIESTA LIQUOR
Date of Testing:
11/14/16
Faci
lity Address:
2023 BAKERS ST
Facility Contact:
ED
Phone:
Date Local Agency Was Notified of Testing :
Name of Local Agency Inspector (if present during testing):
CHRIS KARNS
TESTING CONTRACTOR INFORMATION
Company Name:
BSSR INC
Technician Conducting Test:
NATHAN HOLMAN
Credentials:
CSLB Contractor ICC Service Tech.
SWRCB Tank Tester Other (Specify) __________________
License Number(s):
8111067,672812
SPILL BUCKET TESTING INFORMATION
Test Method Used:
Hydrostatic
Vacuum
Other (Specify)____________________________
Test Equipment Used:VISUAL
Equipment Resolution:
Identify Spill Bucket (By Tank Number, Stored Product, etc.)
1
87
2 89
3 91
4
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:
12
12"
12"
Bucket Depth:
12
12"
12
Wait time between applying vacuum/water and start of test:
0
0
0
Test Start
Time (TI):
10:15
10:15
10:15
Initial Reading (RI):
10"
11"
10"
Test End Time (TF):
11:15
11:15
11:15
Final Reading (RF):
10"
11"
10"
Test Duration (TF
– TI):
1 HR
1 HR
1 HR
Change in Reading (RF - RI):
0
0
0
Pass/Fail Threshold or Criteria:
VISUAL
VISUAL
VISUAL
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:_________________________