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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 (if applicable), should be provided to the facility ownerioperator for submittal ro the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: I Date of Testing: <br />Facility Address: �j ct , cAT� c- /--s TLI <br />Facility Contact: �,� 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: Champion Precision Testing Inc. <br />Technician Conducting Test: ZrAL_1,� <br />Credentials': 0 CSLB Contractor [x] ICC Service Tech- ❑ SWRCB Tank Tester 0 Other (Spec) <br />License Number(s): T Z S Q ti 2- cT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: [x] Hydrostatic 0 Vacuum 0 Other <br />Test Equipment Used: Caldwell Level Change Indicator <br />Equipment Resolution: .0025" <br />Identify SpiIi Bucket (Bv Tank <br />Number, Stored Product, etc.) <br />i -2 6J P s' , <br />21� 7 £4 r! <br />3 9 l <br />4 91 <br />Bucket Installation Type: <br />0 Direct Burr <br />R'C'ontained in Sump <br />0 Direct Bun <br />L<ontaiued in Sump <br />1-2DirectBun- <br />CXoutained in Sulu <br />0Direct Bur\ <br />5 -Contained in Stuu <br />Bucket Diameter. <br />2 <br />1 Z" <br />1 L` <br />I z" <br />Bucket Depth: <br />` ` <br />C ` ' <br />q <br />Wait time bet-Ni-een applying <br />vacuutiVivater and start of test: <br />Test Start Time (T): <br />LJ (go <br />j `t v v <br />l fJ 0 <br />`(o O <br />Initial Reading (R,): <br />I 1 /I <br />` t <br />j (' l <br />r ( `' <br />Test -End Time (TF): <br />6 t7 <br />o <br />Final Reading (RF): <br />Test Duration (TF - TI): <br />Change in Reading (RF - RD: <br />Pass/Fail Threshold or <br />Criteria : <br />Test Result: <br />0 Pass ail. <br />Pass 0 Fail <br />0 Pass IVFail <br />Pass 0 Fail <br />Comments — (include information on repairs made prior to testing and recommended folloit,-up for failed tests) _ <br />9 7 lnJ PrT f-' , ( ( (h £ a l7- <br />--- <br />9t L, et�k (-t C 4-, W to i� r et , K i IL, r <br />CERTIFICATION OF TECEINICIAN 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 />Technician's Signature:yti.� Date: <br />t State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />..+7v hw ,nnw cirintPnt <br />