Laserfiche WebLink
12/14/2015 16:35 2098337676 A ONE GAS PAGE 06/06 <br /> DEC 14 205- <br /> SWF CB,January 2006 <br /> Spill Bracket Testing Report k MIRONMENTAL <br /> This form is intended for use by contractors performing annatal testing of UST spill containment structures. The completed farm and <br /> printouts from tests(:f applicable),sho2dd be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Naxxie: Date of Testing: <br /> Facility Address: (JV, . <br /> Facility Cax►tact: }r-r . Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing). <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: U.S.T.Compliance Testing ic. <br /> Technician Conducting Test: Tony Foutaua <br /> Credentials'. x CSLE Contractor x ICC Service Tech. ❑SWRCE Tank Tester 0 Other(Spec) <br /> License Number(s): 846288 1064273-UT <br /> 3. SPILL BUCIfM TFSTING DWORMATION <br /> Tcst Method Used: x Hydrostatic 0 Vacuum 0 other <br /> Test Equipmeztt Used-RR.2QV nt Resolution: <br /> identify Spill Bucket(By Tank 1 Z ' 3 4 <br /> Number,Stored Product, etc. <br /> Bucket installation Type: MTeet Bury MDirect Bury 0 Direct Bury ❑Direct Bury <br /> ❑Contained in Sump 0 Contained in Su= 0 Contained in SUMP 0 Contaiacd in Sum <br /> Bucket Diameter: <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tt): <br /> Initial Reading W: <br /> Test End Time(TF): <br /> Final Reading(Itr): jJ a <br /> Test Duration(Tr-TO: <br /> kLua <br /> Change in Roading(RF-R): C� <br /> Pass/Fail Threshold or <br /> Criteria, <br /> Fest Result: .R Pass ❑Fall I ]Paas 0 Fail ❑ Pass ❑.Fail ❑ Pass 0 Fall <br /> Comments-(include information on re airs made Prior to testing, and recommended ollow-u for failed tests <br /> �1 <br /> J <br /> CERTWICATION OF T)9CI3NICIAN RESPONsIBI.k.FOR CONDUCTING TKIS TESTING <br /> 1 hereby certify that all the ir{formation eontained in this report is true,accurate,and in full comptlanre with legal requirements. <br /> Technician's Signature: Date:__�.� <br /> 'State laws and regulations do not currently require testing to be perfomed by a qualified contractor-However,local requirernents <br /> may be more stringent. <br />