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SWRCB, January 1.006 <br />Swill Bucket Testing Report Form <br />1 {tis four: is overided t r tae by contras -tors performieg annual testing of UST spill containment structures. The comrletedfotm and <br />rinfinUts from d£S!S f�f�7pl�l;r aljie), should be!.prCi'ideel to tlte.facility oivneriVerator fot SUL` ictal to the [Deal regulatory .agency. <br />_ I. FACILITY INFORNVMATION <br />►Y ; Datt of TestingName-- <br />FacilitName-- AC _ .��... _--- <br />Facility Address: <br />Paciiity Contact' <br />Date Local faLgm <br />Name of Local A <br />['hone: <br />Was Notified of Testing : CX - t v'" I U <br />ncy ltaspect©r (if preseqt during ` / Q0q _ <br />TESTING CONTRACTOR WFORMATION <br />Company Name: Vfr-; _Y___ <br />Trehnician Conducting Test: ` <br />Credentials': 10 SLID Contractor <br />License Numlxr(s C[�� <br />'rest Method Used: <br />Test Equipment Used: <br />Setviee Teat. SWRCB Tax* Tester L ,Cther <br />3. SPILL BUCKET TESTING INk ORM.A►.TION <br />V!LdLosraticY Vacumn cher, <br />uiprnent Resolution: <br />! identify Spill Bucket (,By Tank 1. <br />3 4 <br />Y d1� <br />4D, rl Number. StoredProduct, etc-) <br />'Type: �"iCTtrect Bury <br />r <br />Direr <br />irect Bttr} I L�irect Bary r Bary � <br />Bucket ln.stailation <br />g Contained in Sump <br />— <br />❑ Contained in Stun i Con ` ed in Sum ! i Contained in Sump o <br />i17,4,7r <br />_ <br />Bucket Diameter. XY <br />Bucket Depth: <br />Wait time between applying i <br />n <br />V <br />l <br />vacuum/water and start of test: ' 1 Y <br />Test Start Time dT;): ) I-- <br />r <br />initial Reading (R T14 <br />_.._ <br />l <br />j <br />_ <br />Test 1✓tld Tittle (Tp): � r <br />Final Reading (R.p). <br />40t; <br />Test Duration M: — Tr): <br />Change in RQading (RF -RO: <br />Pass'Fail Thre'huld yr <br />Criteria: 6eC L� <br />VId <br />ss D Fadi <br />i <br />L._ �Q_ <br />_ <br />Test Result: VPass J Fail <br />Pass Q Fail <br />11 Pass t7 Fall <br />Comments —(include it far mgtian Un repair s made ri�estinK ctnd recommended tollow-u for failed teys <br />CERTIFICATION OF TECHNICIAN RESPONS[RLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report is true, accurate, and in full compllftnee with legal requirements- <br />Tecimician's Sipature: -- — Date: <br />'State luws and regulations do not currently rcquire testing to be perfarmcd by a qualified contractor. Hawcver, local requirements <br />may be more stringent. <br />