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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Names: V( o Z (� �l Date of Testing: <br /> Facility Address: <br /> Facility Contact: '1 C1— Phone: _ <br /> ^\ - <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ELITE IV CONTRACTORS <br /> Technician Conducting Test: <br /> Credentials': CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other(Spec) <br /> License Number(s): L C r, :, I (" 1 , 1 r, r✓- P: I <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic Vacuum Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(B),Tank 1 <br /> Number,Stored Product, etc.) �` 1 ` } 2(Dk,- � ` ,\� . 3 Qi <br /> iC- `1 `\) ,) • 4 <br /> Bucket Installation Type: X Direct Bury X Direct Bury X Direct Bury Direct Bury <br /> Contained in Sump Contained in Sump Contained in Sunip Contained in Sum <br /> Bucket Diameter: }D, <br /> Bucket Depth: } <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): ,- <br /> Initial Reading(Rt): -� , S r j t 1 • r <br /> Test End Time(TF): <br /> Final Reading(RF): C- C, j <br /> Test Duration(TF—TD: :t�ffl <br /> Change in Reading(RF-Rj): <br /> Pass/Fail Threshold or <br /> Criteria: flSS S <br /> Test Result: X Pass ❑Fail Pass ❑Fail Pass ❑Fail Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> t <br /> 1 U <br /> L` llFJ ` �' �C \ ( <br /> Q <br /> CvV a -�eO _\ l` <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> JJ ; <br /> Technician's Signature: L�— Date: <br /> r State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />