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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 from tests(if applicable), should be provided to'the facility owner/operator for submittal to the local regulatory agocy. <br /> 1. ,�:':CILITYINEOR�VIA�IO�'�t <br /> Facility Name: trC�v U _S- t- Date of Testing:. <br /> Facility Address: / 3 v Sder,��e Gt/i/Soret ylee% �TrJG/G 0's �<i• SZ!>5� <br /> --F acility Contact: '�, a,uj Vic-� W t.q t,+,.•fir / <br /> Date Local Agency Was Notified of Test`fig.: U l 0 -7 <br /> Name of Local Agency Inspector,(if presi nl during toy.ting): <br /> 2. TESTING,.G ..TT).tACTOR.INFORMATION <br /> Company Name: 2 T -t <br /> Technician Conducting <br /> .Credentialst: CSLB Contractor ICC SerVice ec . CB Tank Tester Other(Speci#) <br /> License Number(s): l l ZL.3 <br /> Tcsk Method Used: osttatie Vac`utYi i. (31 fir <br /> Test Equipment Used:' a n: �.1 �� , Z S <br /> 1 �ne t? �rsu�� <br /> E ui" mstitResolutio <br /> Identify Spill Bucket($y ank 11"-owl je_*' � 2-� 1fi 3 3 4. <br /> Number,Stored Product, etc.) 5u ne y re.t t t4 Wer V4 P / <br /> .13ucket Installation Type: I iiect$ur D rec Bu erect 1#nry Direct Bury <br /> ontatned`n S Contax a um QQntamed;in Su C nta iced in Sump <br /> y.eket Diameter: p r��►i lv <br /> .ii ket Depth: . . !Y e/Ze <br /> Wait time between applying <br /> vacuuY :ate nd start of test: /0 M.e + a-� /� `. 4t S <br /> `fest Start Time(T): <br /> Initial Reading(R): V311 <br /> t+ t s. <br /> Test End Time(TF): <br /> /5— <br /> ,Final <br /> —Final Reading(Rp): 1 ` c f r t 1 3 t t r f <br /> Test Duration(TP—TO: f a u Y' U U[ / <br /> Change in Reading(RF-RD: 'Af <br /> -itss/Fail Thteshold or <br /> ry <br /> C7teria: <br /> 74 <br /> i t� �4 <br /> 7 r n+ Vii. WIN A'ES 11 k J N 11 1 <br /> ( i. j , recommended f <br /> 21 <br /> CQlllll]CI1kS— include information ott rr p irs inade prior to tes a and, olloW-up fpr failed tests <br /> CERTIFICATION OF TE,CHNICI.AN RESPONSIBLE FOR CONDUCTING .THIS TESTING <br /> I hereby certify that'all the information contained in tl' report is true, accurate,and in full compliance with-legal requirements. <br /> Technician's Signature �,_ f...:,..•-- (,. r..-c r A^~-Al Date• d ��/CJ / <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 />