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Work(Drder: 2249172 <br /> SWRCB,Jmuuary 2006 <br /> Spill Bucket Testing Report Form <br /> TAnform b Jntendedfor we by cor roctors prrjorming onnaa.'testing ofLisT'spill wntaurment structww. The completedfa and <br /> prirdanUfrom tests(tfaWicable),should be provided to thefacility ownerldperatorfor sabndnal to the local mgele=ory agancy, <br /> 1. FACILITY INFORMATION <br /> Facility Nems: '1 Date of Testing: <br /> Facility Address: <br /> Facility Conbict: Phoria: <br /> Dote Fatal Agency Was Notified of Testing: <br /> Name of Locel Agency Inspector(ifprt unt daring toting): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Tact <br /> Credartials': 0 CSLB Contractor ce Teeh. _-SW RCB Tack Tetter C Outer Opscify) <br /> License Nun*=(*. <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used WHydrostirlic ]V aeumn D Ober <br /> Tcst Equipment Used: Equipment Ri,wiwion: <br /> Identify Spill Bucket(By Tank 1 ';2 + 3 4 <br /> Number,Stored Produa,etc. T 1 <br /> Bucket Installation Type: Direct Bury irect Bury D Direct Bury C Direct Bmy <br /> ''D Contained in SUMD.Contained in Sump ❑Contained N Stun CCoMained m Sump <br /> Bucket Diametw.. I 1 <br /> Er et Depth: ' <br /> Wait time between applying <br /> vautmnAvafer and stmt of last: M. <br /> Test Start Time(fa: !dd <br /> Initial Reading(Rt): <br /> Test Pad Tina:(Tvr Ig' .� <br /> Final Reading(RA <br /> Test Duatical M—TIX rite yyl' <br /> Cheap in Reading 04-Rt): `t <br /> PasslFwl Threthoki w <br /> Criteria: 0ti QZrYj <br /> Teat Result: D Fail Peso 'C Phil D Pate D F111 13 Paas 13 Eau <br /> Co eats—(mdade iavmazjom on mpoirspadepriff to rrsy ad, ended fllow, or arled tau) <br /> J 1C- �� '�Y"l � <br /> CERTIFICATION OF TECHNKYAN RESPONSIBLE FORCONDUCTM THIS TESTING <br /> I hereby certify that as rke information tro br thk rapers is Ere,aetsnsnee,and is fatl mmpGance wfth Jega7a; <br /> emertfs. <br /> Technician' tote: Date: rU <br /> 'State laws and Tegulationa do not curreniffy require teadngto be pofmmed by a qualified contractor.Howcr ,Itaal"eenaents <br /> maybe coma stringent <br /> Tanknology Inc. 8501 N.MoPac Expressway,Suite 400,Austin,Texas 78759 <br />