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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended far 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 /> FacilityName: e-k-,c Date of Testing: el - (- <br /> Facility Address: y.l i 2.G <br /> Facility Contact Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION_ _ <br /> Company Name: C ty-r- <br /> Technician <br /> Technician Conducting Test: r^ T e, r^,q r <br /> Credentials': ❑CSLB Contractor 9-fCC Service Tech ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: &Ifydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Co Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) g 7 91 1 0 4 E <br /> Bucket Installation Type: ❑Direct Bur, ❑Direct But% ❑Direct But- ❑ irect Bur <br /> Q"Contaiued in Sum i�ntahted in Sump— C3�'ontained in Sump ❑ outaiued in Sum <br /> Bucket Diameter: <br /> Bucket Depth: 17 <br /> Wait time bem een applying <br /> acuum/nater and start of test: 10 n`t? !d <br /> Test Start Time(T,): 70 O 1310 <br /> Initial Reading(RJ: leie- / <br /> Test End Time(TF): Z O O G <br /> Final Reading(RF): <br /> Test Duration(TF-T4): <br /> Change in Reading(RF-RI): <br /> Pass/Fail Threshold or n}_ <br /> Criteria 4-60/ t7 <br /> Test Result: Pass ❑Fail Pass ❑Fail LVPass ❑Fail ❑ Pass ❑Fail <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up forfailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> /hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: a Date: <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor. However,local requirements <br /> m o..M morn ctrin nnnt <br />