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... ..i <br /> 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: circ L Date of Testing: 11 S p <br /> Facility Address: -,7,b-7 E5 t7� fi'1Je� T A A- CM-371, <br /> (e <br /> Facility Contact: 1=je4T Pte: <br /> Date Local Agency Was Notified of Testing: /a /-Zz j 07 <br /> Name of Local Agency Inspector(ifpresent during testing): Re--r-r 3y a kkr <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. 0 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: .0025" <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number,Stored Product, etc.) 87 9 l YPfEScz <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> 81(ontained in Sump 8'Contained in Sump ldIContained in Sump 11 Contained in Sump <br /> Bucket Diameter: 2 Z I Z <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: 5 A a-7 k r aJ S h rJ <br /> Test Start Time(Td: p FY.f S /e a <br /> Initial Reading(It,): Co 0 <br /> Test End Time(TF): /o !S /o! !!3 0 <br /> Final Reading(RF): cal 4� Q' <br /> Test Duration(TF—Td: /%+,r %4 k y t r, <br /> Change in Reading(RF-Rd: 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> riteria: <br /> , <br /> �...., .;..:... v4:.. ' ... ,� <br /> � s , <br /> : ,105-W-5. <br /> Y. <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certify that all the information contained in this report Ls true,accurate,and in full compliance with legal requirement& <br /> Technician's Signature: Date: 1115-10-7 <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 />