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Work Order: 2248888 <br /> swRCB,January zoos <br /> Spill Bucket Testing Report Form <br /> Tuts form is hvended for use 4 v vatraaors performing annual testing of UST split conralnmenr structures-711c completed form and <br /> printouu from tests(rf vppgcable),should he prnvided to thefacility owner/operator far submidal to the local regulotory agency. <br /> L FACILITY INFORMATION <br /> Facility Name: 4,o-1!7 IDate of Testin 2 <br /> Facility Address- g-,70 <br /> w g r <br /> .Ncsr/.•,.., <br /> FacilityCantact /}� ✓ Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(Ifprewr during reslirrgl: <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ! _,Ax <br /> Technician Conducting Test: 21y1 <br /> Credentials I: u CSL13 Contractor Service Tech. 0 SW RCB Tank Tester iJ Other(Specify)_ <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Tcst Method Used: 8-Hydrostatic 0 Vacuum 0 Other _ <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tam* I 2 <br /> Number,Storedproduc;etc. �I �� 'r1:t.`✓ 3 �'� _fl,,, 4 / <br /> fl Direct Bu 0 Direct <br /> Bucket Installation Type: Bury Bury U Direct Bury ❑Direct Bury <br /> FContained in Su u Contained in Sump 0 Containad in Su 0 Contained in Sum <br /> Bucket Diameter: /L /71—.-- /Z- <br /> Bucket Depth: /D r D r <br /> Wait time between applying -- `— <br /> vacuumfwater and start of test ?� Y <br /> Test Start Tune(T,r <br /> Initial Reading(Rt): '�,7r <br /> 7r 9F- <br /> Test End Time(Tr). /t':3 / 1 Z d __ '1 D 114o! <br /> t <br /> Final Reading(Rj): IJ_-Yjr <br /> 7r <br /> y <br /> of T 7� <br /> Test Duration(Tr T,): 6D , u <br /> Change in Reading(RF-Rt); <br /> Pass/Fail Threshold or P P P <br /> Criteria: <br /> Test Result: JI -Pass .0 Fail .-�p pass C nil Pass 0 Fail —1)Pass p Fail <br /> omimeii is—{include imfornmrion on repairs made prior to testing,and reeommendedfallow-up for falled tests) <br /> CERTIFICATION OFTECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby cen y that all the atfornterlon contained in d6is report k true,aeeurme,ane to full compliance with legal requirermntc <br /> Technician's Signature: 10(4— Date: f`-L-I <br /> 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 /> Tanknology Inc. 8501 N. MoPac Expressway, Suite 400,Austin, Texas 78759 <br />