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Feb 02 10 10. 05a Elite TV Contactors 12094816342 <br /> 0 G, rv4 <br /> Spill Bucket Testing Report Form SWRCB,January 2006 <br /> Prins farm is inlendcd for riser contractors performing annual testing of UST spill containment structures. The completed form and <br /> Pr tou ,tom testi (if apl1licable),should lie provided to thajacility owner/operator for submittal to the local regulatory agency_ <br /> y r_ IA�ITYINFORtiIAT[ON <br /> Facility Name; <br /> - <br /> C <br /> Facility Address: Date of Testing: <br /> � � �— <br /> Facrlity Contact: , 0 <br /> _ Phone; J� <br /> Date Local Agency Was Notified of 1 csting 15,; <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR]INFORMATION <br /> CotMany Name: <br /> Technician Conducting Test_ u <br /> Credentials i: NCSLB Contractor CC service Tech D SWRCF3 Tank Tester __Qther(Specify) 1 <br /> License Ntunner(s}: <br /> SPII L BUCIKET.TESTING:rNFOLtmATION <br /> Test Method Used: 0 Hydrostatic 0 Vacuum 0 Other <br /> Test Equipment UsecL <br /> Equipment Resolution: <br /> Identify Spill Bucket((By Tank l 2 <br /> Number;Stored Product,etc- . 4 <br /> Bucket Installation Type_ b Dircct Bury D Direct Bury Direct Butt' 0 Direct$ <br /> 0 Contained in S C1 Contained in S 0 Contained in S m5' <br /> Bucket Diameter; ii 0 Contained in Su <br /> Bucket Depth: <br /> Wait time between applyira , <br /> vacuurnN�ater and start of test- E <br /> Tcst Start Time(Ti): <br /> Initial Reading(Ro: <br /> Tcst End Time(TF)--- <br /> Final <br /> TF):Final Reading(RF): <br /> TestDuration(TF—•1p& <br /> Ch rage 1St Reading(RF-Ri): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> CUIuittents—tinclude information an re airs made prior to testing,'and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTINGTRIS TESTING <br /> Ilrerchy certify lltat ult the information.contained in Arcs report is trite,accurate„and in full complrrrjrce will,.le>;el requirements.. <br /> Technician's Si <br /> State laws and re Mations do not currently require testing to be performed by a qualified contractor,Ilowevcr,Joe <br /> may be more stringent. al requirements <br />