Laserfiche WebLink
Dec l,6 08 08: 20a Elite IV Contactors 12084616342 p. 4 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors perfOrming a theancesiinQ f UST spill n peraror for containment <br /> submittal tottures <br /> he logia regulatory agency. <br /> y and <br /> printoutsfrom tests (if applicable), should be provided to f t5 <br /> 1. FACILITY INFORMATION <br /> Date of Istin;: <br /> Facility Name: 1 4, � 1 � <br /> C � <br /> Facility.'address: Phone: <br /> Facility Contact: f` <br /> Date Local Agency Was Notified of Testing,: �} <br /> Name of Local Agency Inspector(if preseei during testing): <br /> 00 n <br /> 2. TESTING CONTRACTOR INFORMATION. <br /> ConVany Name: <br /> Technician Conducting Test: �� '' (P5 ecz fy) <br /> Credentialsi: ❑CSLB Contractor -•ICC Service Tech. 0 SWRGB T Tester ❑Other <br /> Licezzse?vurnber(sj: � `"Y _ �`�' <br /> 3. SPILL BUCKET TESTING XNFORMATION <br /> 0 Vacuum 0 Other <br /> Tcst Method Used: "§Hyd ostatic Equipment Resolution: <br /> Test EquiptMnt Used: <br /> _ Z 3 4 <br /> Identify Spill Bucket(By Tank I <br /> Number,Stored Product, etc.) 0 Direct Bury 0 Direct Bury <br /> 6LDirect Bury f Direct Bary <br /> Bucket Installation Type: 0 Cotitaine<i its S 0 Contained in 5 0 Contained in Su ❑Confined iAt Sunza <br /> Bucket Diameter: <br /> Bucket Depth: 3 ~ <br /> Wait tune between applying <br /> vacuumrwater and start of test: <br /> s <br /> Test Start Time(TO: t <br /> Initial Reading(Rs)= <br /> Test End Time(TF): <br /> Final Reading(RF): <br /> Test Duration(TF—Tj): <br /> Change in Reading(RF-R¢): <br /> pass/Fail Threshold or Pry <br /> Criteria. � <br /> Ctzxnments—(include reformation an re airs made prior to tc>_strng, and recam�eended follow- for failed tests) <br /> ti 1 1' lif 1 <br /> CER'T'IFICATION Olt'TECHhICIAN RESI�O�SIB ue FOR�01"a,"dUtn fallCTIK aTHIS cence TESTING al requirements.. <br /> 1 hereby certify that all the information contained in this.rep / <br /> F <br /> Date: '"�/ <br /> Technician's Signature: <br /> y a qualified contractor,However,local requirements <br /> State <br /> laws and regulations do not currently require testing to be performed b <br /> may be more striagerrt. <br />