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gWRCB,January 2006 <br /> � <br /> pjlj iLlci►et � sting Report Forin <br /> orm is intended for use by contractors performing an+n~al testing f Spill araor subm it to the local reKulattructures. The lory agency etedfirm and <br /> nments <br /> This,form <br /> printouts from tests(if applicable),should be provided to the,facility ar'ner/per' <br /> T. <br /> FACILITY INi'ORMATIG-�1Date of Testing: s <br /> Facility Name: r, <br /> Facility Address: - Phone: <br /> Facility Contact: - - <br /> Date Local Agency Was Notified of Testing: _� -.- -.. i _, •4 <br /> Name of Local Agency inspector(gipresent during testi'`V' <br /> 2. TESTING CONTRACTOR FORMATION4'company Nacne: U.S.T.Compliance Testing Inc, <br /> Technician ConductingETest: Tony Fontana Credentials': x CSL,Bactor x ICC Service Tech. <br /> SWR Cl3 Tank Tester 0 Other(Spec <br /> License Number(s): &46288 t OM-73-UT <br /> 3. SPILL B L;CKET TESTING iNF004ATIOIS <br /> x Hydrostatic i 3 Vacuum C3 Other <br /> Test Method Used: y Equipment Resolution: <br /> Test Equipment Used: i�aE!���'�� -- -- <br /> .� <br /> Identify Spill Bucket(By Tank l • <br /> Number,Stored product. etc..) ❑Direct Bury �7 Direct Bury <br /> ❑Direct Bury 3 Direct P.ur}• <br /> Bucket Installation Type: ontained in Sum o Ctonntained in Sum <br /> Contained in Sum Contain d in Sum <br /> .t ; <br /> Bucket Diameter: til <br /> Bucket Depth. <br /> Wait time between applying <br /> vac water and start of test: it{, <br /> Test Start Time{T�: �� 1 <br /> Initial Reading(R4): t 3 <br /> Test End Time(TF): <br /> Final Reading(RF): � <br /> Test Duration(TF-TO: - b <br /> Change in Reading{RF-R►): - ,, <br /> Pass/Fail Threshold or <br /> Criteria: - <br /> Test Resntt• � Pass ❑fall ____. �Pa,-s ❑Fail Pass-- ❑ Fail .wF�"l'ass - Fail <br /> Comments-(include information on repatrs made r,�rstir,to te <br /> , and recommended follow-up for failed tests1 __ _ <br /> CER'T'IFICATION OF TECHNICIAN RESPONSIBLE FUR CONDUCTING THIS TESTING <br /> I heretic'cerZF r that ail the infoyn"an contained in this report k,MMA accwale,and in full compliance with legal requirements. <br /> n-- — <br /> Technician's Signature: Date:,y <br /> ` State laws and regulations do not current y require testing,to be per:otmed by a qualified contractor.However, local requirements <br /> may he more stringent. <br />