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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 /> printouts from tests(if applicable),should be provided to the facility ownerioperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: =E- I Date of Testing: <br /> Facility Address: 1jr rj( - r C V AA <br /> h--f~ <br /> Facility Contact: tj( Ott, Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing: t <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Champion Precision Testing_Inc. <br /> Technician Conducting Test: JC <br /> Credentials': D CSLB Contractor fxj ICC Service Tech_ D SWRCB Tank Tester D Other(Specify) <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used_: Ixj Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Caldwell Level Change Indicator Equipment Resolution: .0025" <br /> Identify Spill Bucket(By Tank I ? 2 ( 3 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: irect Burt Direct Burt- * irect Bun- 0 Direct Burt <br /> D Contained in Sum D Contained in Sump u Contained in Suinp D Contained in Snuu <br /> Bucket Diameter. f t r 2- <br /> t r, <br /> Bucket Depth: <br /> Wait tine between applying ! d �` f� � 64f� t <br /> tacut n/�tater and start of test: <br /> Test Start Time(T): ' C3 0 <br /> Initial Reading(RI): ' ► "� `t 3 `' <br /> If <br /> Test-End Time(TF): I6 6 <br /> Final Reading(RF): a 3 <o r/ <br /> Test Duration(TF-TI): t / A / <br /> Change in Reading(RF-RD: <br /> Pass/F0 Threshold or <br /> Criteria: <br /> Test Result: Ef Pass D Fay;Pass D Fail 1fass D Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended folloiv-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,aecurate,and in full compliance with legal requirements. <br /> Technician's Signature: Cz Date: <br /> ie- �' � <br /> ' State laws and regulations do not currently require testu►g to be performed by a qualified contractor-However,local requirements <br /> cnav ho mnro CfAr+ee+mt <br />