Laserfiche WebLink
v <br />SVJRCB, January 2006 <br />Spill uc 'et 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 />7 <br />I IC ♦ !'TT*i'V TXT1UnDM A TT(1N 1 <br />FacilityName:Royg_ilni (1,.67- Date of Testing: <br />Facility Address: /'gyp S_ OLA <br />Facility Contact: c 5 Phone: 2_0cl <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (ifpresent during testing): �� <br />� r�crrTNr_ rnNTRerTnR 1NFtlRMATT(1N <br />Company Name: c55 S SO _ - ,h, OI <br />Technician Conduc ' g Test: <br />Credentials: GrCSLB Contractor 01CC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 17t &Gf <br />z cvrr r Rink -UT TTCTTNr_ TNFnRMATION <br />Test Method Used: Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Equipment Resolution: t e (, ti <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 <br />2 Cz <br />3 <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />❑ Contained in Sump <br />E)D''�ect Bury <br />ontained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />13"1 <br />Bucket Depth: <br />i <br />aj} <br />Wait time between applyingRt:u <br />vacuum/water and start of test: <br />4x <br />.-.-� <br />Test Start Time (T): <br />/ Z. Io <br />I <br />J U S <br />Initial Reading (R): <br />17 // <br />Test End Time (TF): <br />3d <br />ENVIR <br />ENTAL <br />Final Reading (RF): <br />ct i/ <br />HEA • fff <br />4 <br />Test Duration (TF - Ti): <br />( c.►i <br />Change in Reading (RF - Rj): <br />;11 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />❑ Pass ❑ Fail <br />MrPass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all thMn contained in this report is true, accurate, and in full compliance with legal requirement, <br />Technician's Signature: _ Date: 1��_ -2-0 Yr <br />' State laws and regula 0 8'�do not currently require testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />