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1y <br /> 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(if applicable),-should be provided*fo the` c.t ity-Fiivner/operator or submittal to the local regulatory agency. i <br /> 1. FACILITY INFORMATION <br /> Facility Name: ,G-, j rFN a K) 7- T- -4 r V Date of Testing: / 9 '7 <br /> Facility Address: SI-?,* r/4e Gf I✓ rr> <br /> Facility Contact:-*.r 6w ; 7-�'Ile, Phone: ( 20 � �2-- <br /> Date Local Agency Was Notified of Testing. /' 3® a,7 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING.CONTRACTOR MORMA,.TION <br /> Company Name: ri ru. r e f z' S r 7 <br /> Technician Conducting Test: 414r,y r F, GGA-f <br /> Credentials': CSLB Contractor t'TC�C Service Tech. SWRiZ h Tank Tester Other(Specify) <br /> License Number(s):W)-/fes rJ c�t� 2 Y .7`'7727lf 7` <br /> 3. SPIT:L.BUCKET TESTJNG INFQRMATION <br /> Test Method Used: dro5tatie Vacuum other <br /> 'fest Equipment Used: j a: o �!r:, ,r EquspmBnCsResolutian: ' � " x 2 5 r <br /> Identify Spill-Bucket(By Tank 2' c t42' <br /> y +-..`� � 3 <br /> Number,Stored Product, etc. 1-i I I f I ( 1 r <br /> Bucket Installation Type: pirc:fu Diretti. `Direct Bury <br /> Contained in Sum Contained in Sum Contained in Sum L 6ntained in rn <br /> Bucket Diameter: 12 te /2 it <br /> Bucket Depth: j 2-1P <br /> Wait time b tween applying <br /> vacu.0 rwateo and start of test; 16 r•r S <br /> Test Start Time(TO: /Z.) N f- - <br /> �.Initial Reading(RO: `r/ 11y Gt <br /> Test End Time(TF): <br /> _Final heading(RF): t lL, <br /> Test Duration(TF--Tt): � ur <br /> 04ange in Reading(RF-Rj: t r <br /> ','Pass/Fail Threshold or <br /> r f 1 <br /> teria: �f r�,'t r11 Y?IrLCo� 1 f� rpt <br /> ' k <br /> Comxner t - (include inform.r o repairs made prior to testing; grin recommended allow-u or'.a:led'tests) F <br /> � [ � <br /> / t <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certify that all the infgrmation contained in t7reort is trite, accurate, and in full compliance with legal requirements. <br /> r� <br /> f <br /> Technician's Signatur / -� J tom_ .— f / `f <br /> Date: / <br /> t 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 />