HomeMy WebLinkAboutFMC 2019&(56 &DOLIRUQLD(QYLURQPHQWDO5HSRUWLQJ6\VWHP,' ,GHQWLILFDWLRQ,&& ,QWHUQDWLRQDO&RGH&RXQFLO< <HV1 1R1$ 1RW$SSOLFDEOH
81 ZZZXQLGRFVRUJ 5HY
81'(5*5281'6725$*(7$1.
021,725,1*6<67(0&(57,),&$7,21)250 3DJHRI
7KLVIRUPPXVWEHXVHGWRGRFXPHQWWHVWLQJDQGVHUYLFLQJRIXQGHUJURXQGVWRUDJHWDQN 867 PRQLWRULQJHTXLSPHQW$FRS\
RIWKLVIRUPPXVWEHSURYLGHGWRWKH867RZQHURURSHUDWRU7KHRZQHURURSHUDWRUPXVWVXEPLWDFRS\RIWKLVIRUPWRWKHORFDO
DJHQF\UHJXODWLQJWKH867VZLWKLQGD\VRIWKHGDWHRIWKHPRQLWRULQJV\VWHPFHUWLILFDWLRQ
, )$&,/,7<,1)250$7,21
&(56,''DWHRI0RQLWRULQJ6\VWHP&HUWLILFDWLRQ
%XVLQHVV1DPH(Same as Facility Name or DBA-Doing Business As)
%XVLQHVV6LWH$GGUHVV &LW\ =,3&RGH
,, 81'(5*5281'6725$*(7$1.6(59,&(7(&+1,&,$1,1)250$7,21
1DPHRI&RPSDQ\3HUIRUPLQJWKH&HUWLILFDWLRQ 3KRQH
0DLOLQJ$GGUHVV
1DPHRI8676HUYLFH7HFKQLFLDQ3HUIRUPLQJWKH&HUWLILFDWLRQ(Print as shown on the ICC Certification)
&RQWUDFWRU7DQN7HVWHU/LFHQVH ,&&&HUWLILFDWLRQ ,&&&HUWLILFDWLRQ([SLUDWLRQ'DWH
0RQLWRULQJ6\VWHP7UDLQLQJDQG&HUWLILFDWLRQV(List all applicable certifications.) ([SLUDWLRQ'DWH
,,, 5(68/762)7(67,1*6(59,&,1*
Indicate and attach the following reports if the monitoring equipment is capable of generating either.<11$0RQLWRULQJ6\VWHP6HWXS$ODUP+LVWRU\5HSRUW
:DVDQ\PRQLWRULQJHTXLSPHQWUHSODFHG"
(If “Yes,” identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.)
:DVGDPDJHGHEULVRUOLTXLGIRXQGLQVLGHDQ\VHFRQGDU\FRQWDLQPHQWV\VWHPV"
(If “Yes,” describe what was found in section IV below.)
,VDOOPRQLWRULQJHTXLSPHQWRSHUDWLRQDOSHUPDQXIDFWXUHU¶VVSHFLILFDWLRQV"
(If “No,” describe why in section IV below.)
,9 &200(176
If directed to use this section, describe how and when the issues were or will be corrected.
9 &(57,),&$7,21%<8676(59,&(7(&+1,&,$1&21'8&7,1*7+,67(67,1*
,KHUHE\FHUWLI\WKDWWKHHTXLSPHQWLGHQWLILHGLQWKLVGRFXPHQWZDVLQVSHFWHGVHUYLFHGLQDFFRUGDQFHZLWK&DOLIRUQLD&RGHRI
5HJXODWLRQV7LWOH'LYLVLRQ&KDSWHU6HFWLRQDQGDOOLQIRUPDWLRQFRQWDLQHGKHUHLQLVWUXHDQGDFFXUDWH$WWDFKHGWR
WKLVFHUWLILFDWLRQLVLQIRUPDWLRQ HJPDQXIDFWXUHUV
FKHFNOLVWVPRQLWRULQJV\VWHPVHWXSDODUPKLVWRU\UHSRUWHWF QHFHVVDU\
WRYHULI\WKDWWKLVLQIRUPDWLRQDQGWKHVLWHSODQVKRZLQJWKHOD\RXWRI867V\VWHPLVFRPSOHWHDQGDFFXUDWH
8676HUYLFH7HFKQLFLDQ6LJQDWXUH
%XLOGLQJ
10172773 2/21/2019
Bill Wright Toyota
5100 Gasoline Alley Drive Bakersfield 93313
16250 Meacham Road, Bakersfield, CA 93314
Aaron Perrigo
804904 8485827 9/14/2020
INCON 1010993708 8/17/2020
Confidence UST Services, Inc. (800) 339-9930
,' ,GHQWLILFDWLRQ6: 6LQJOH:DOOHG93+ 9DFXXP3UHVVXUH+\GURVWDWLF//' /LQH/HDN'HWHFWRU
81 ZZZXQLGRFVRUJ 5HY
81'(5*5281'6725$*(7$1.
021,725,1*6<67(0&(57,),&$7,21)250 3DJHRI
9, ,19(1725<2)(48,30(17&(57,),('
A separate Monitoring System Certification Form must be prepared for each monitoring system control panel.
0DNHRI0RQLWRULQJ6\VWHP&RQWURO3DQHO
0RGHORI0RQLWRULQJ6\VWHP&RQWURO3DQHO
6RIWZDUH9HUVLRQ,QVWDOOHG
Check the appropriate boxes to indicate specific equipment inspected/serviced.
0RQLWRULQJ'HYLFH8VHG'HYLFH0RGHO0RQLWRULQJ'HYLFH8VHG'HYLFH0RGHO
7$1.,'
(By tank number, stored product, etc.)
7$1.,'
(By tank number, stored product, etc.)
,Q7DQN*DXJLQJ(SW Tank),Q7DQN*DXJLQJ(SW Tank)
$QQXODU6SDFHRU9DXOW6HQVRU$QQXODU6SDFHRU9DXOW6HQVRU
93+6HQVRU93+6HQVRU
3URGXFW3LSLQJ3URGXFW3LSLQJ
0HFKDQLFDO//'0HFKDQLFDO//'
(OHFWURQLF//'(OHFWURQLF//'
93+6HQVRU 3LSLQJ 93+6HQVRU 3LSLQJ
6XPS6HQVRU6XPS6HQVRU
93+6HQVRU 6XPS 93+6HQVRU 6XPS
)LOO3LSLQJ)LOO3LSLQJ
93+6HQVRU 3LSLQJ 93+6HQVRU 3LSLQJ
6XPS6HQVRU6XPS6HQVRU
93+6HQVRU 6XPS 93+6HQVRU 6XPS
9HQW3LSLQJ9HQW3LSLQJ
93+6HQVRU 3LSLQJ 93+6HQVRU 3LSLQJ
6XPS6HQVRU6XPS6HQVRU
93+6HQVRU 6XPS 93+6HQVRU 6XPS
9DSRU5HFRYHU\3LSLQJ9DSRU5HFRYHU\3LSLQJ
93+6HQVRU 3LSLQJ 93+6HQVRU 3LSLQJ
6XPS6HQVRU6XPS6HQVRU
93+6HQVRU 6XPS 93+6HQVRU 6XPS
0RQLWRULQJ'HYLFH8VHG
'HYLFH0RGHO0RQLWRULQJ'HYLFH8VHG
'HYLFH0RGHO
7$1.,'
(By tank number, stored product, etc.)
7$1.,'
(By tank number, stored product, etc.)
,Q7DQN*DXJLQJ(SW Tank),Q7DQN*DXJLQJ(SW Tank)
$QQXODU6SDFHRU9DXOW6HQVRU$QQXODU6SDFHRU9DXOW6HQVRU
93+6HQVRU93+6HQVRU
3URGXFW3LSLQJ3URGXFW3LSLQJ
0HFKDQLFDO//'0HFKDQLFDO//'
(OHFWURQLF//'(OHFWURQLF//'
93+6HQVRU 3LSLQJ 93+6HQVRU 3LSLQJ
6XPS6HQVRU6XPS6HQVRU
93+6HQVRU 6XPS 93+6HQVRU 6XPS
)LOO3LSLQJ)LOO3LSLQJ
93+6HQVRU 3LSLQJ 93+6HQVRU 3LSLQJ
6XPS6HQVRU6XPS6HQVRU
93+6HQVRU 6XPS 93+6HQVRU 6XPS
9HQW3LSLQJ9HQW3LSLQJ
93+6HQVRU 3LSLQJ 93+6HQVRU 3LSLQJ
6XPS6HQVRU6XPS6HQVRU
93+6HQVRU 6XPS 93+6HQVRU 6XPS
9DSRU5HFRYHU\3LSLQJ9DSRU5HFRYHU\3LSLQJ
93+6HQVRU 3LSLQJ 93+6HQVRU 3LSLQJ
6XPS6HQVRU6XPS6HQVRU
93+6HQVRU 6XPS 93+6HQVRU 6XPS
INCON TS-1000 6.600
Unleaded
847390-109
LS6
FX1V
LS6
,' ,GHQWLILFDWLRQ93+ 9DFXXP3UHVVXUH+\GURVWDWLF8'& 8QGHU'LVSHQVHU&RQWDLQPHQW
81 ZZZXQLGRFVRUJ 5HY
81'(5*5281'6725$*(7$1.
021,725,1*6<67(0&(57,),&$7,21)250 3DJHRI
0RQLWRULQJ'HYLFH8VHG'HYLFH0RGHO0RQLWRULQJ'HYLFH8VHG'HYLFH0RGHO
9(1775$16,7,216803,' 9(1775$16,7,216803,'
6XPS6HQVRU6XPS6HQVRU
93+6HQVRU93+6HQVRU
8'&,' 8'&,'
(OHFWURQLF6HQVRU(OHFWURQLF6HQVRU
0HFKDQLFDO'HYLFH0HFKDQLFDO'HYLFH
93+6HQVRU93+6HQVRU
8'&,' 8'&,'
(OHFWURQLF6HQVRU(OHFWURQLF6HQVRU
0HFKDQLFDO'HYLFH0HFKDQLFDO'HYLFH
93+6HQVRU93+6HQVRU
8'&,' 8'&,'
(OHFWURQLF6HQVRU(OHFWURQLF6HQVRU
0HFKDQLFDO'HYLFH0HFKDQLFDO'HYLFH
93+6HQVRU93+6HQVRU
8'&,' 8'&,'
(OHFWURQLF6HQVRU(OHFWURQLF6HQVRU
0HFKDQLFDO'HYLFH0HFKDQLFDO'HYLFH
93+6HQVRU93+6HQVRU
2WKHU0RQLWRUHG&RPSRQHQW,' 2WKHU0RQLWRUHG&RPSRQHQW,'
2WKHU(Specify in section VII.)2WKHU(Specify in section VII.)
2WKHU0RQLWRUHG&RPSRQHQW,' 2WKHU0RQLWRUHG&RPSRQHQW,'
2WKHU(Specify in section VII.)2WKHU(Specify in section VII.)
2WKHU0RQLWRUHG&RPSRQHQW,' 2WKHU0RQLWRUHG&RPSRQHQW,'
2WKHU(Specify in section VII.)2WKHU(Specify in section VII.)
Include information for every underground storage tank component monitored by this monitoring system control panel. If the monitoring system
control panel monitors more components than this form accommodates, additional copies of these pages may be attached.
9,, &200(176
Use this section to provide additional comments about the inventory of the equipment certified.
1
Boudreaux fiber optic
< <HV1 1R1$ 1RW$SSOLFDEOH
81 ZZZXQLGRFVRUJ 5HY
81'(5*5281'6725$*(7$1.
021,725,1*6<67(0&(57,),&$7,21)250 3DJHRI
9,,, 021,725,1*6<67(0$1'352*5$00,1*
This section must be completed if a monitoring panel is used to perform leak detection monitoring.<11$
$UHWKHYLVXDODQGDXGLEOHDODUPVRSHUDWLRQDO"
:HUHDOOVHQVRUVYLVXDOO\LQVSHFWHGIRUNLQNVDQGEUHDNVLQWKHFDEOHVDQGIRUUHVLGXDOEXLOGXSWRHQVXUHWKDWIORDWVPRYHIUHHO\
IXQFWLRQDOO\WHVWHGDQGFRQILUPHGRSHUDWLRQDO"
:HUHDOOVHQVRUVLQVWDOOHGDWORZHVWSRLQWRIVHFRQGDU\FRQWDLQPHQWDQGSRVLWLRQHGVRWKDWRWKHUHTXLSPHQWZLOOQRWLQWHUIHUHZLWK
WKHLUSURSHURSHUDWLRQ"
:DVPRQLWRULQJV\VWHPVHWXSUHYLHZHGWRHQVXUHSURSHUVHWWLQJV"
:DVWKHPRQLWRULQJSDQHO¶VEDFNXSEDWWHU\YLVXDOO\LQVSHFWHGIXQFWLRQDOO\WHVWHGDQGFRQILUPHGRSHUDWLRQDO"
'RHVWKHIORZRIIXHOVWRSDWWKHGLVSHQVHULIDOHDNLVGHWHFWHGLQWKHXQGHUGLVSHQVHUFRQWDLQPHQW"
'RHVWKHWXUELQHDXWRPDWLFDOO\VKXWGRZQLIWKHSLSLQJVHFRQGDU\FRQWDLQPHQWPRQLWRULQJV\VWHPIDLOVWRRSHUDWHRULVHOHFWULFDOO\
GLVFRQQHFWHG"
'RHVWKHWXUELQHDXWRPDWLFDOO\VKXWGRZQLIWKHSLSLQJVHFRQGDU\FRQWDLQPHQWPRQLWRULQJV\VWHPGHWHFWVDOHDN"
:KLFKVHQVRUVLQLWLDWHSRVLWLYHVKXWGRZQ"(Check all that apply.)6XPS8QGHU'LVSHQVHU&RQWDLQPHQW
,IDODUPVDUHUHOD\HGWRDUHPRWHPRQLWRULQJVWDWLRQLVDOOFRPPXQLFDWLRQVHTXLSPHQW HJPRGHP RSHUDWLRQDO"
For any answer of “N” above, describe in Section IX how and when these deficiencies were or will be corrected.
,; &200(176
; ,17$1.*$8*,1*7(67,1*
&KHFNWKLVER[LIWDQNJDXJLQJLVXVHGRQO\IRULQYHQWRU\FRQWURO(Do not complete this section.)
<11$&KHFNWKLVER[LI12WDQNJDXJLQJHTXLSPHQWLVLQVWDOOHG (Do not complete this section.)
This section must be completed if in-tank gauging is used to perform leak detection monitoring.
+DVDOOLQSXWZLULQJEHHQLQVSHFWHGIRUNLQNVDQGEUHDNVLQWKHFDEOHVDQGIRUSURSHUHQWU\DQGWHUPLQDWLRQLQFOXGLQJWHVWLQJIRU
JURXQGIDXOWV"
:HUHDOOLQWDQNJDXJLQJSUREHVYLVXDOO\LQVSHFWHGIRUGDPDJHDQGUHVLGXHEXLOGXSWRHQVXUHWKDWIORDWVPRYHIUHHO\IXQFWLRQDOO\
WHVWHGDQGFRQILUPHGRSHUDWLRQDO"
:DVDFFXUDF\RIV\VWHP¶VSURGXFWOHYHOUHDGLQJVWHVWHG"
:DVDFFXUDF\RIV\VWHP¶VZDWHUOHYHOUHDGLQJVWHVWHG"
:HUHDOOSUREHVUHLQVWDOOHGSURSHUO\"
:HUHDOOLWHPVRQWKHHTXLSPHQWPDQXIDFWXUHU¶VPDLQWHQDQFHFKHFNOLVWFRPSOHWHG"
For any answer of “N” above, describe in Section XI how and when these deficiencies were or will be corrected.
;, &200(176
*3+ *DOORQV3HU+RXU< <HV1 1R1$ 1RW$SSOLFDEOH93+ 9DFXXP3UHVVXUH+\GURVWDWLF,' ,GHQWLILFDWLRQ
81 ZZZXQLGRFVRUJ5HY
81'(5*5281'6725$*(7$1.
021,725,1*6<67(0&(57,),&$7,21)250 3DJHRI
;,, /,1(/($.'(7(&7257(67,1*
&KHFNWKLVER[LIOLQHOHDNGHWHFWRUV //' DUH127LQVWDOOHG(Do not complete this section.)<11$This section must be completed if LLDs are installed.
:DVDOHDNVLPXODWHGWRYHULI\//'SHUIRUPDQFH"
(Check all that apply.)6LPXODWHGOHDNUDWHYHULILHG *3+*3+*3+
:DVWKHWHVWLQJDSSDUDWXVSURSHUO\FDOLEUDWHG"
)RUHPHUJHQF\JHQHUDWRUWDQNV\VWHPVGRHVWKH//'FUHDWHDQDXGLEOHDQGYLVXDODODUPZKHQDOHDNLVGHWHFWHG"
)RUPHFKDQLFDO//'VGRHVWKH//'UHVWULFWWKHIORZWKURXJKWKHSLSHZKHQDOHDNLVGHWHFWHG"
)RUHOHFWURQLF//'VGRHVWKHWXUELQHDXWRPDWLFDOO\VKXWRIIZKHQDOHDNLVGHWHFWHG"
)RUHOHFWURQLF//'VGRHVWKHWXUELQHDXWRPDWLFDOO\VKXWRIILIDQ\SRUWLRQRIWKHPRQLWRULQJV\VWHPLVGLVDEOHGRUGLVFRQQHFWHG"
)RUHOHFWURQLF//'VGRHVWKHWXUELQHDXWRPDWLFDOO\VKXWRIILIDQ\SRUWLRQRIWKHPRQLWRULQJV\VWHPPDOIXQFWLRQVRUIDLOVDWHVW"
)RUHOHFWURQLF//'VKDYHDOODFFHVVLEOHZLULQJFRQQHFWLRQVEHHQYLVXDOO\LQVSHFWHGIRUNLQNVDQGEUHDNV"
:HUHDOOLWHPVRQWKHHTXLSPHQWPDQXIDFWXUHU¶VPDLQWHQDQFHFKHFNOLVWFRPSOHWHG"
:HUHDOO//'VFRQILUPHGRSHUDWLRQDOZLWKLQUHJXODWRU\UHTXLUHPHQWV"
For any answer of “N” above, describe in Section XIII how and when these issues were or will be corrected.
;,,, &200(176
;,9 9$&88035(6685(+<'5267$7,&021,725,1*(48,30(177(67,1*
&KHFNWKLVER[LI93+PRQLWRULQJLV127XVHG(Do not complete this section.)
This section must be completed if VPH monitoring is used to perform leak detection monitoring.
6\VWHP7\SH 0DUNDOOWKDWDSSO\ 9DFXXP3UHVVXUH+\GURVWDWLF
6HQVRU,'&RPSRQHQW 6 0RQLWRUHG%\7KLV6HQVRU 6HQVRU)XQFWLRQDOLW\
7HVW
,QWHUVWLWLDO&RPPXQLFDWLRQ
7HVW
3DVV )DLO 3DVV )DLO
3DVV)DLO3DVV)DLO
3DVV)DLO3DVV)DLO
3DVV)DLO3DVV)DLO
3DVV)DLO3DVV)DLO
3DVV)DLO3DVV)DLO
3DVV)DLO3DVV)DLO
3DVV)DLO3DVV)DLO
3DVV)DLO3DVV)DLO
3DVV)DLO3DVV)DLO
3DVV)DLO3DVV)DLO
3DVV)DLO3DVV)DLO
+RZZDVLQWHUVWLWLDOFRPPXQLFDWLRQYHULILHG"6LPXODWHG/HDNDW)DU(QGVRIWKH,QWHUVWLWLDO6SDFH9LVXDO,QVSHFWLRQ
2WKHU(Describe the method in section XV below.)*DXJH
:DVWKHYDFXXPRUSUHVVXUHUHVWRUHGWRRSHUDWLQJOHYHOVLQDOOLQWHUVWLWLDOVSDFHV"<HV1R(Describe the reason in section XV below.)
For any answer of “Fail” above, describe in Section XV how and when these issues were or will be corrected.
;9 &200(176
&(56 &DOLIRUQLD(QYLURQPHQWDO5HSRUWLQJ6\VWHP,' ,GHQWLILFDWLRQ867 8QGHUJURXQG6WRUDJH7DQN,&& ,QWHUQDWLRQDO&RGH&RXQFLO
81 ZZZXQLGRFVRUJ5HY
81'(5*5281'6725$*(7$1.
63,//&217$,1(57(67,1*5(3257)250 3DJHRI
7\SHRI$FWLRQ,QVWDOODWLRQ7HVW5HSDLU7HVW0RQWK7HVW
, )$&,/,7<,1)250$7,21
&(56,''DWHRI6SLOO&RQWDLQHU7HVW
%XVLQHVV1DPH(Same as Facility Name or DBA-Doing Business As)
%XVLQHVV6LWH$GGUHVV &LW\ =,3&RGH
,, 81'(5*5281'6725$*(7$1.6(59,&(7(&+1,&,$1,1)250$7,21
1DPHRI8676HUYLFH7HFKQLFLDQ3HUIRUPLQJWKH7HVW(Print as shown on the ICC Certification.) 3KRQH
&RQWUDFWRU7DQN7HVWHU/LFHQVH ,&&&HUWLILFDWLRQ ,&&&HUWLILFDWLRQ([SLUDWLRQ'DWH
6SLOO&RQWDLQHU7HVWLQJ7UDLQLQJDQG&HUWLILFDWLRQV(List applicable certifications.)
,,, 63,//&217$,1(57(67,1*,1)250$7,21
7HVW0HWKRG8VHG 0DQXIDFWXUHU*XLGHOLQHV(Specify)
,QGXVWU\&RGHRU(QJLQHHULQJ6WDQGDUG (Specify)
(QJLQHHUHG0HWKRG(Specify)
Attach the testing procedures and all documentation required to determine the results.RI$WWDFKHG3DJHV
7$1.,' (By tank number, stored product, etc.)
6SLOO&RQWDLQHU0DQXIDFWXUHU
0HWKRGRI&DWKRGLF3URWHFWLRQ 1RQ0HWDOOLF1RQ0HWDOOLF1RQ0HWDOOLF1RQ0HWDOOLF
,VRODWLRQ,VRODWLRQ,VRODWLRQ,VRODWLRQ
2WKHU(Specify in V.)2WKHU(Specify in V.)2WKHU(Specify in V.)2WKHU(Specify in V.)
,QVLGH'LDPHWHURI6SLOO&RQWDLQHU (Inches)
'HSWKRI6SLOO&RQWDLQHU (Inches)
'RHVWKHVSLOOFRQWDLQHUKDYHDJDOORQFDSDFLW\"<HV1R<HV1R<HV1R<HV1R
0HWKRGWR.HHS6SLOO&RQWDLQHU(PSW\ 'UDLQ9DOYH'UDLQ9DOYH'UDLQ9DOYH'UDLQ9DOYH
2QVLWH3XPS2QVLWH3XPS2QVLWH3XPS2QVLWH3XPS
2WKHU(Specify in V.)2WKHU(Specify in V.)2WKHU(Specify in V.)2WKHU(Specify in V.)
,9 6800$5<2)7(67,1*5(68/76
6SLOO&RQWDLQHU7HVW5HVXOWV 3DVV)DLO3DVV)DLO3DVV)DLO3DVV)DLO
9 &200(176
Any items marked “Fail” above must be explained in this section. Any additional comments may also be provided here.
9, &(57,),&$7,21%<8676(59,&(7(&+1,&,$1&21'8&7,1*7+,67(67,1*
,KHUHE\FHUWLI\WKDWWKHVSLOOFRQWDLQHUVZHUHWHVWHGLQDFFRUGDQFHZLWK&DOLIRUQLD&RGHRI5HJXODWLRQV7LWOH'LYLVLRQ
&KDSWHU6HFWLRQDQGDOOWKHLQIRUPDWLRQFRQWDLQHGKHUHLQLVDFFXUDWH
8676HUYLFH7HFKQLFLDQ6LJQDWXUH
If the facility has more components than this form accommodates, additional copies of this page may be attached.
Bakersfield 93313
804904 8485827 9/14/2020
OPW 0148613
PEI 1200
1
T1 fill
OPW
11.00”
13.00”
T1 vapor
OPW
11.00”
13.00”
Aaron Perrigo (800) 339-9930
10172773 2/21/2019
Bill Wright Toyota
5100 Gasoline Alley Drive
SWRCB, 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 for submittal 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:
Technician Conducting Test:
Credentials1: CSLB Contractor ICC Service Tech. SWRCB Tank Tester Other (Specify) __________________
License Number(s):
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: Hydrostatic Vacuum Other
Test Equipment Used: Equipment Resolution:
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.
Bill Wright Toyota 2/21/2019
5100 Gasoline Alley Drive Bakersfield 93313
Summer Hankins (661) 398-8697
1/31/2019
Kris Karns
Confidence UST Services, Inc.
Aaron Perrigo
804904 8485827
Lake Test 0.0625”
T1 fill T1 vapor
11.00” 11.00”
13.00” 13.00”
5 min 5 min
9:00am 9:00am
12.25” 12.25”
10:00am 10:00am
12.25” 12.25”
1 hr 1 hr
0.00” 0.00”
0.0625” 0.0625”
2/21/2019
✔✔
✔
✔✔
✔✔