Laserfiche WebLink
Dec 21 2007 11 : 48AM HP LASERJET FAX p . 3 <br /> SWRCB,January 2006 <br /> Spill Baeket 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 thefacility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACIL TY INFORMATION <br /> Facility Name: ; 7z -h Date of Testing: / Z-/0-0-7 <br /> Facility Address: yD YD GcJ ST 4 4r k-- <br /> Facility Contact: ryll" !f E 4E 1 Phone: 7-01-6,9,3 - 703,4 <br /> Date Local Agency Was Notified of Testing : /Z- S—O <br /> Name of Local Agency Inspector(if present during testing): /} z- <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Aleryt 6-mo. 3t✓ " e rOrP <br /> Technician Conducting Test /47? MOLL <br /> Credentials`: LB Contractor LACC Service Tech. SRRCB Tank Tester Other(Specify) <br /> License Number(s): Q SZ S0-3,/g 7 -a <br /> 3. SPALL BUCKET TESTING INFORMATION <br /> Test Method Used: ChydrostZVacuum Other <br /> Test Equipment Used: ,Q ,y r Equipment Resolution: l/1gpA� <br /> Identify Spill Bucket(By Talk 1 V )LI, rx7L. 2 urVL6 Vr1Por't 3 P50- FV-4.- 4 AIASrl7rc A5-1,L. <br /> Number, Stored Product, eta u.,t 000 044) QJOW /2-//-0 <br /> Bucket Installation Type: rect B rzect B < nettE qzrect <br /> Contained in Sump Contained in Sump Contained in Sump Contained in Sump <br /> Bucket Diameter: <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: /D eV :')tJ / / t+2.rrJ 0 <br /> Test Start Time(T): 5• <br /> Initial Reading(Rt): td/Y- y iY1 f <br /> Test End Time(TF): / (r / 0:/(,6 <br /> 13 l b <br /> Final Reading(RF): q /3l /ylr} ryi uiY1 <br /> Test Duration(TF-Ti): / ,yarl / ffD*� /{�ytt <br /> Change in Reading(RF-Rj): . - <br /> Pass/FailThtresholdor yp V-r,ruAt_ ^Vo YSSuA4- NO vx-5uA1- rdo Jz3'u44- <br /> Criteria: j•.ps Lp3SS1tV- <br /> - <br /> igg <br /> R <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up forfailed tests) <br /> z1,4-3a BTZ. N"� IIZtd_JtZ IG�4�L — REPU4Gt i) A oE,,9-.T71J ✓i44JEyry /2'If. 07 <br /> R�rEsr€fl - �A�SED 7 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TEEIS TESTING <br /> I hereby certify that all the lmformadon contained in this report is true, accurate, and in full compliance with legal requirements. <br /> Technician's Signature: VUA- Date: / Z -/4 —07 <br /> ' 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 />