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Spill Bucket Testing Report Form SWRCB, January 2006 <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br />printouts front tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />FacilityName: / ,,t t Date of Testing:02 — — Q <br />Facility Address: f c <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (if present during testing): <br />7 TFCTTNf" d-r1NTD A r'rnn T1\T/1n1 l . T...., <br />Company Name: C ' <br />Technician Conducting Test: a f <br />Credentials: ❑ CSLB Contractor ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) _ <br />License Number(s): •$" Zs' qc <br />n <br />3. SILL BUCKET TESTING INFORMATION <br />i est Metnod Used: —r"1 -I drostatic ❑ Vacuwn ❑ Other <br />Test Equipment Used: t6 /a t.>G I l <br />I Equipment Resolution: <br />Identify Spill Bucket (By Tank 1 <br />N'urnber, Stored Product, etc.) <br />2 <br />q1 <br />3 n <br />/✓ l <br />4 <br />Bucket Installation Type: Duect Bun <br />FE Contauied in Sunt i <br />mn' eet Bu <br />❑ Contained i=ii Sunip <br />Direct But,_ <br />❑ Contained in Sunip <br />❑ Duect Butt <br />0 Contained in Sulu <br />Bucket Diameter: f?—' t <br />j Z e, <br />l Z' <br />Bucket Depth: 12 11 <br />N <br />j <br />Wait time between appl\in- <br />W acuuutibe ater and start of test /0 A' , <br />%U �''� <br />/ Q ` R <br />Test Start Time (T,): 0 � 0 4) <br />9.3 <br />t1 v <br />Initial Reading (R,): 10 '' <br />/ / el <br />f/ " <br />Test End Time (TF): <br />1660 <br />6 O <br />Final Reading (RF): tor <br />/ I `,, <br />/ / ' <br />Test Duration (TF — T,): 3U ry r a( <br />'34) m / A <br />:)6 M, y1 <br />Change in Reading (RF - Rt): <br />Pass,'Fail Thi-eshold or <br />Criteria <br />,n t <br />Test Result: Pass ❑ Fail <br />Pass ❑ Fail <br />Pass ❑ Fail <br />❑ Pass ❑ Fail <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 is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: ` Date: 3 ct 7 <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />vv»v kP mew. ctrinaPnt <br />