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@`J/ Hb/ Lobb It. 314 1 f OU O LtaA�v 1 <br />SWRCB, Jonuary ?Nati <br />Spill Bucket Testing Report Form, <br />Tka form is nwandffd for zise &V eer"'vors {e?rT»itpo artaual tnttrg cf, r 5T soul rnnlaTnmrrnr Jrrutlura. The tonrpIated form rntd <br />yF7FllciiltS 1rTG7f SaiF; (i}c:yYiiiwvTl moi. Shd'Ylyl be rrG idS rb 1�.!_�?Ciir�+ awRtT'%�trdlor or ,Ff bmatal r8 the local r�tttCtl7rY QgB7tC*' <br />1. FACILITY MORM/*` ION <br />Faollity Name: Daw of Testinj: <br />Facility Addtrss: <br />LO <br />FacI iiy Ciartd:.: Phanr_ <br />Date Local Agotsty Was Notified of Testing ; 4 <br />Fame of Local Agency Inspcz:oor lif present during rrVmV: <br />2. 'TESTING CONTRACTOR INFORMATION <br />FCom any Name! <br />Technician Cendwing Test, <br />hi Cradcft®ala : CSLB Contactor ICC 5ern= Tech. SWRCB Tank Tasw Other eeti5O <br />rLicame Numbts(s), <br />Terse Method UW: Hydrostatic Vacautz► Other <br />Test Equipatent Used: Equipment Resolution: <br />Id=it`y Spill Bucket (By Tank 1 Z 3 4 <br />Nytnber, $toned Frodticr. arc, f r_3_r4 1L4 <br />Mr"t Bury I <br />Dvtct Bury <br />I Duct Bwy i <br />Direct Bim <br />Ty <br />I $'1iCifEt Insta.latton : VFe. <br />jIt S <br />Cowamed to 5 <br />Contai�i ift S <br />Contattted Su. <br />10 A/ i <br />' <br />l <br />Buciaac Dienxtstar: <br />8u�i;zt Depth: <br />Wait that betv+aw apply-ing <br />I <br />I I <br />vaC=MtWStff 2Ad SM -t O: t ---.I: <br />163t Stan Time ri. IY <br />f 7 1 <br />i <br />Initial Reading M): <br />r <br />Test End Time (rj,): <br />4 <br />Fine., Resdzka (RF)' <br />t /::J <br />ost DUM100 (Tr — Tlr <br />i <br />Change in ReWing (Rtr- Rl): <br />i <br />Pass/Fail Tttteth�{d yr <br />j <br />f <br />C ritetia: <br />Tcst PtesQb <br />it Pass ❑Fall <br />Q Pisa C Fail I @ Pais G Fail <br />4ojamenU — (Include? er t;r.R --hon C" Ffkatrs mad! , im <br />Tr to leET a Mamrn <br />�nraw ci11V.v-Y <br />CI;>li'IMCA.TION OFTECTXqTCLkN RESFONS BLI£ FOR CCiiyi3UCIM-46 SIS TESTRtG <br />r #crabs "Mp rtear air sire nrfo,ynadeor eonrrdted in frit repaR b true fice"GM, wed in *H coxplsnes wIM kg -al rembmwenm <br />�{'�y�� <br />Technician's S*Rtw.e:. Lf '1M <br />' State laws and reaula> ions do not currently regzura testm% to be peffoTmad by a ct:aiifi d conrr'sct*r. However. local requirements <br />may be more stringent <br />