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• • SWRCB,January 2006 <br /> Spill Bucket Testing'Rep6o Form <br /> This form is intendedfor use by contractors performing annual testing of UST spill containment structures. The completedform and <br /> printouts from tests(f applicable),should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACuXrY INFORMATION <br /> Facility Name: G i-,o n <br /> Date of Testing: <br /> Facility Address: C2 Zc./ i 'V(Y <br /> Facility ContactPh e: _ <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testingl: <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Cham ion Precision Testing, Inc,_; <br /> Technician Conducting Test: <br /> Credentials: o CSLB Contractor 97CC Service Tech. 0 SWRCB Tank Tester 0 Other(Specify) <br /> License Number(s): Lic#848150 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: drostatic 0 Vacuum 0 Other <br /> Test Equipment Used: Zf 7' Equipment Resolution: <br /> Identify,Spill Bucket(By Tank 1 2 _73 4 <br /> Number,'Stored Product, etc <br /> Bucket Installation Type: ' 0 Wn=t T14 945irect Bury @ Direct Bury 0 Direct Bury <br /> 0 Contained in Sump 0 Contained in Sump 0 Contained in Sump 0 Contained in Sum <br /> Bucket Diameter. _ ` <br /> Bucket Depth: �, % % Ij �2 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TO: O: O 2 O '20 <br /> 0 <br /> Initial Reading(R>): <br /> a ,/ <br /> Test End Time(Tp): //.' �v / „s� <br /> Final Reading(RF): g' ; 3i t l/ <br /> Test Duration(TF—TJ. Y <br /> Change in Reading(RF- <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pau 0 Fail'-` R Pass 0 Fail JO Pass 0 Fail 0 Pass 0 Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up forfailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby cabfy that all the information contained in this report is true,accurate,aced in fu/I compliance with legal requiremerd& <br /> Technician's Signature: �i Date: �7 _ <br /> Z7 Oyv d 7-- <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />