Laserfiche WebLink
SWRCB,January 2006 <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 owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: f a Date of Testing: /Z-l0-07 <br /> Facility Address: l)Yo T 44tti.c:-:� <br /> Facility Contact: Mj N'CLLE 4CPhone: )a- 7L939 <br /> Date Local Agency Was Notified of Testing: / Z- S'-0 '7 <br /> Name of Local Agency Inspector(ifpresent during testing): L " <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: A 67120, -7Z 1/ ' ' dr d.170C D12A, <br /> Technician Conducting Test: C U <br /> Credentials: LB Contractor C Service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number(s): 9 8 52523 6 -7 - U <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: 7Hydrost9lP Vacuum Other <br /> Test Equipment Used: -1019a -r- Equipment Resolution: ✓lS{,y� <br /> Identify Spill Bucket(By Tank 1 t4A)Lp rX-U 2 WVL6 yAPe% 3 bfF5Q 1„ 4 WASTI'triz r i <br /> Number, Stored Product, etc. 000 0104) AW /2.-//-0-7 <br /> Bucket Installation Type: irect B uect uect uect <br /> Contained in Sump Contained in Surrip Contained in S Contained in Sumv <br /> Bucket Diameter: t' 1 ( " 111 <br /> r 11 11 <br /> Bucket Depth: 3 3/y 3 s/ 2 I/ 3 3/ /1 <br /> Wait time between applying <br /> vacuum/water and start of test: /n"%YW / ^U-AJ Q � <br /> Test Start Time(T1): S-- 1/11-5- : 1 s 2' )5- <br /> Initial Reading(R1): / /J7yvT r-/I1 <br /> Test End Time(TF): / : 16, / 2 <br /> Final Reading(RF): tq �y &A4<- <br /> Test <br /> A4 Test Duration(TF-TO: / ygu e / Ai�ulz Z /10-u <br /> Change in Reading(RF-R1): .� <br /> Pass/Fail Threshold or /'r„ /j t iV0 ✓SSUAL n/a y13aAL oo <br /> Criteria: ; :� .2 LO 4.O S-S %��s> <br /> Test Result: ass Fail s Failss ) Fail ass Fail <br /> Comments- (include information on repairs made prior to testing, and recommended follow-up for jailed tests) <br /> UI A -477- &7Z eft i/LSV&- F74 2z. - R C7L44Act 1) )kfl•.nU ✓ lL ort /2'//- 07 - <br /> RErEbrEb - htsscp ncz- <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in fuU compliance with legal requirements. <br /> Technician's Signature: //(/VIM VUA/ Date: 7 <br /> 1 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 />