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SWRCB,January 2006 <br /> Spill Bucket 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 /> pruttouts froartests(if applicable), should be provided to the facility owner/gperatorfor submittal to the local regulatory agency. <br /> 1.. FACILITY INFORMATION <br /> Facility Name: Date of Testing: tZ• -t <br /> Facility Address: tat w. sr <br /> Facility Contact: Phone: -3! <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): <br /> Z. TESTING CONTRACTOR FORMATION <br /> Company Name: 1.. <br /> Technician Conducting Test: Us- afla <br /> Credentials': CSLB Contractor TCC Service Tech. SWRCB Tank Tester Other(specify) <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFOWMATION <br /> Test Method Used: Hydrostatic Vacuum. Other <br /> Test Equipment Used: Equipment Resolution: <br /> IdentifySpillBucket(By Tank „y1 -.w2 �� '4 <br /> ,Number,Stored Product, etc.) <br /> Bucket Installation Type: Direct Suzy Direct Bury Direct Bury Direct Bury <br /> Contained in Sum Contained ip§unN Contained in SuMp Contained in Supp <br /> Bucket Diameter. <br /> Bucket Depth: <br /> Wait time between applying <br /> vaeuunVwater and start of test: <br /> Test Start Time(Tl): <br /> Initial Reading(R):' <br /> Test End Time(Ta): <br /> Final Reading(RF): <br /> Test Duration(TF-TO: <br /> Change in Reading(Rr-R): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> sk. .r;.' ,`. p..x'qq•'M':" .. ���^� Wr _F...- ��ia�l•:.�,X' :I-c7',:d''r9 i, i.l:-:• +��: _ -4. <br /> Test Resci�t's.f " d � 5 " .ALrvT: '4` a tp 6S r"S! a1�f C Pasfi �'81h' <br /> CO7IX11cI iWts--(include information on repairs made rior to testing, and recoravnended allow-u for ailed tests) <br /> � t <br /> C`EIiTIFICATION OF TECHNICIAN RESPONSMUI F'OR CONDUCTING TfuS TESTING <br /> I hereby certify that all ilia information contained in this report is true,accurate,and in full compliance with Legal requirements. <br /> Technician's Signature; - Date: C <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 />