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FROM :B.Z.SERVICESTATION MAIN" aNCE FRX NO. :916 371 2540 Rug. 07 2006 03:21PM P5 <br /> •,� wr <br /> SWRCB,January 2W6 <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 ownerloperator far submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: a Date of Testing: e-7s- C <br /> Facility Address: P:"7 9 q &-.?, GOAK W ip, x zb'l ^ <br /> Facility Contact: ko^400,X— 6/b - <br /> Date Local Agency Was Notified of Testing: (37- 2-9'-6d6 <br /> Name of Local Agency Inspector(if present during testing): T. t/OA/ �L Lt � <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Co Name: 13 z- Ehr -r "rrmz),v ehli <br /> Technician Cond ICS ." a rk <br /> Credentials': LB Conttacto ICC Service Tech, SVVRCB Tank Tester Other(Specify) <br /> license Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: C Hydrostatic Vacuum Other _ <br /> Test Equipment Used: JCS Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number Stored Product, etc. <br /> Bucket Installation T Direct Bury Direct Bury Direct Bury Direct Bury <br /> Type; Contained in Sump Contained in Smnp ,- _ Contained in Sump Contained in SumLt_ <br /> Bucket Diameter: 2 �� 2'4;, <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): ,p,jOri w� R � �� _.•.... <br /> Initial Reading(R,): ` 7a <br /> Test End Time(T,:): /OAn n- <br /> Final Reading(Rn): 1-170 <br /> Test Duration(TN-Ti): D .e.77v O s+^t--V, <br /> Change in Reading(Rr.-Rj): _ <br /> Pus/Fail Threshold or �„/ � <br /> Criteria: .G7 <br /> Test Result: 0 Fall U45ra C1 Fail 0 Pass 0 Fail 0 Pan 0 Fall <br /> Comments-(include information an repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the info contain,in this report is true,accurate,and in full compliance with legal requirements. <br /> 't'echnician's Signature: --- Date: 0$ 'roV--C19 <br /> t 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 />