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1 1 <br /> SWRCB,January 2006 <br /> Spill B°ucket 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 the facility owner/operator for submittal to the local regulatory a ncy. ' <br /> 3 <br /> L •F.-CILITY MMAT" <br /> Facility Name: r--r-G o'4-1-- v e) Date of Testing v / Q <br /> Facility Address: t D 5 o u-4 lel (,U 1 S a� t A.l�� 5 C jG C�, .. $�-�? <br /> Facility Contact: �i w ✓ cQ .l�t.q�� :. Phone:. (-,,_ D�'��t�f 3' 2 - <br /> .Date Local Agency Was Notified of Tes ` g.: d It l . d 7 <br /> Name of Local Agency Inspector.(ifp'resant during testing): <br /> 2. TFSTING00N,TRACTOR INFORMATION <br /> Company Name:2 f-7 co v,,,0 1 1 ccs,•c c. T-,s 4-ti,- <br /> Technician Conducting.Test: I'3 A. (fit, ut <br /> ,Credentials`: CSLB Contractor C Service.Te CB Tank Tester Qther(Specify) <br /> License Number(s): l RZU <br /> $UCS;INk'OMW <br /> Test Method Used: <br /> Test Equipment Used: u r I Egturnt 1te$btton: a (�" �C s l <br /> Identify Spill Bucket(By Tank 1 TG,t(Gx' d- 2 -FCW'V 4�-2 414 :4- <br /> Number,Stored Product, etc.) 2e'9 u(fie✓. I,t( r2eg y tm,.✓Vq p?)r- pl a <br /> Bucket Installation Type: Direct ur. d6ctBur birserBury: Direct B <br /> ontained.in,Sumon ' n 'ne C.ontaine.'d in Sum <br /> ticket Diameter: p lift t f p .j i f 11 l t7' ►t <br /> Bucket Depth: i s 31 �� I LI 3) `a � �3/40 <br /> Wait ti b <br /> ween applying <br /> vacu u ter a d start of test: /(I r a t gra.µE 4'_S 4 es 109 <br /> Test Start Time(TI): �! ' v f ; Z G7 Z 5'" <br /> .,Initial Reading(RD: /�y° / 3 !�L a 3 <br /> Test End Time(TF): w ) Z-0 V z 2- Z �-- <br /> F.inal Reading(RF): !� / 37/T77 <br /> //Z a ! S //2- <br /> T-est <br /> /LTest Duration(TF-TO: /tet U 11.0 L-4 ✓ <br /> Change in Reading(RF-RI): <br /> ra, s/ ail Tht'eslivld or / / <br /> Criteria: l/�� '�1 _f�G h{� ,//�� !4 �//l fly. /Ab l i f� hou✓ /�� 1;,7 <br /> ,; .. DIMMER <br /> - <br /> Comments- include <br /> ( information on'repairs-made prior to testing, and recommended follotiy up fpr failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained inlh` report is true,accurate, and in full compliance With legal requirements. <br /> Technician's Signature: Date: ( ,/J//-3/ <br /> 1 State laws and regulations do not currently require testing to be p rformed by a qualified contractor.However, local requirements <br /> may be more stringent.- <br />