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1' <br /> swRCB,January 2006 <br /> SO11 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 bpgorovided to the factlity owne.r/operatorfar submittal to the local regulatory agency. <br /> Facility Name: p,G.f G . <br /> T3ate of Testing:, 3 <br /> Facility Addtess; 6t W S+ �t� }•eh t �Gt ZO <br /> 1slcilityContact: r L.g, :. Phpn.. . d O Z�'7 <br /> :.Date Local Agency Was Notified of`Testing.: <br /> Name of Local Agency Inspector((f presentduzing te-Cting):. ( 4-W�.. _� LAS <br /> 2. TESD' IG CONTRACTOR IINF2� : N <br /> Company Name: <br /> -PecfmicianConductingTes[:'�j.e,,,. < <br /> �Yedentials': CSLE Contractor ICC$eftiice Tee) C$Tat*Teste dta8t 3p�ei,J <br /> LicenseNamber(s): D 11,0 <br /> 3. mwaum T <br /> Test Method Used: <br /> I-)..�ro'gjiftie= <br /> 'test E Apment Used:CEtf eht Its501nTton s o�d S.>. <br /> Iddutify SpillMucket(9yTank I W ose - 2 SVIu p bVIA Y1 '$WP IM" .. . <br /> Nu»tber,Store$Product,etc. L L 7' L- G,,tn <br /> D`ect Btar dried Bury � tom- bisect mry t� uect Bttyy <br /> ricket Installation Type: Cotifamed(it$n Contained iii Sum Con nod"In Snm on 60 in S <br /> poketDiameter: OXZc7"X LO" <br /> }GJcet Depth: <br /> .ait time§zLweeh applying <br /> vaeituater 'd.start'Of test: o -t,xu i Y SV -e S . lb 1 sM IJ c S <br /> eststart Time(TO:. L/S Z <br /> iatitialReading(R>)% vS a(vU - rv5� L'AlL4tt 1 •` <br /> Test End Time(TP): r f / l2.': 'S' l ' Z� <br /> 4 <br /> !A!' <br /> : estDuratioq.(Ti,-Ti�: - 3rd w.aa�,u, ..S 3D t•7rwiw S �..kbit ✓ <br /> Be in ke�lng(RF RD: N O <br /> assail T}u8s)old ar ' <br /> Grteria: od5l361 oo5,�3Dtti^�; l�.I�'1 Cwt dCnl/ <br /> pllrmentS-(riclude info mat:o`n'on re ants made 'rior to teSTin , and recommc`nd d 011o `-u; or aF{ed tests) <br /> �:45� <br /> ljo� l Value a,",S NQ. SUic4Y / Lt 'r <br /> C,IFT CATION OF.TECFNfCLANtSPOtTSIBk E FOIL CONDfJCT Cs HiS TESTING <br /> I hereby certify that all the information contained lret v re ort is trae,accurate, and in full eatitpliattce with legal requirements. <br /> f <br /> Tec)nician's.Signature _ d^'^^^ `' '� ' Dale: �Y <br /> State laws and regulations do not currently require testing to be pe onned by a qualified contractor.However, local requirements <br /> may be more stringent.- <br />