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SWRCB, January 20 <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 as <br /> printouts from tests rf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency <br /> 1. FACILITY INFORMATION <br /> Facility Name: ci c KK L Date of Testing: I I $ O <br /> Facility Address: y o 7 `c 5 at t7-4r A d� /1 n r ,4 Cil R S'33 {o <br /> Facility Contact: FXA-11 Z' I Phone: Zo9-$tS- (,Z-7y <br /> Date Local Agency Was Notified of Testing: /0 /2z 0-7 <br /> Name of Local Agency Inspector rifpresent during testing): 3A c kt x <br /> 4 RE f r / <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Champion Precision Testing Inc. <br /> Technician Conducting Test: Alvin L.Milburn <br /> Credentials[: ❑CSLB Contractor [x]ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 0878949-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [x]Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Caldwell Level Change Indicator Equipment Resolution: .0029' <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) 27 I PfdSt-Z <br /> Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct B <br /> Bucket Installation Type: mS' <br /> R'Contained in Stun 8'Contained in S l�ntained in Sump ❑Contained in Sum <br /> Bucket Diameter: t Z /Z I Z <br /> Bucket Depth: "s- <br /> Wait time between applying <br /> vacuum/water and start of test: 45 A tt> ,,, e o <br /> Test Start Time(fl): p f'(i O?Y a /ea o <br /> Initial Reading(Rt): <br /> Test End Time(TF): <br /> Final Reading(RF): Rs -- <br /> Test Duration(TF-Tt): /%ti r % 11 r L t t, <br /> Change in Reading(RF-R1): 05 <br /> Pass/Fail Threshold or -- <br /> Criteria: <br /> Test Result: El Pass 11 Fail Pass '' U Faii `. it Pass0 Fail Q'Pam 0 Fait' <br /> Comments-(include information on repairs made prior to testing, and recommended ollow-up or ailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> l hereby certdfy that all the information containedin this report is true,accurate,and in full compliance with legal requirement <br /> Technician's Signature: GES c,� Date: t //S7/0-7 <br /> ' State, lnwc and remilatinns do tint ntrrentiv remtire testinn to he aerfnrmed by a nualified cnntrartar Howevermeal renniremem¢ <br />