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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> Thu 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 agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: L dv Dof Testing: <br /> Facility Address: ate�( <br /> Facility Contact: Phone. ?.0 ;j-- 0 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: FAL <br /> Technician Conductin T <br /> Credentials': tractor ICC Service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: drostatic Vacuum Other <br /> Test Equipment Use4: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 <br /> Number,Stored Product, etc.) (J <br /> Bucket Installation Type: erePaineRin <br /> erect u c Direct Bury <br /> n Sum on ame m Sump Contained in Sum2 Contained in Sum <br /> Bucket Diameter: <br /> Bucket Depth: NO f <br /> Wait time between applying rn <br /> vacuum/water and start of test: V <br /> Test Start Time(T,): ('( � 1:6— <br /> Initial <br /> : —Initial Reading(Rj): G0 grto <br /> Test End Time(Tf.): !(s r <br /> Final Reading(R,:): SO d <br /> Test Duration(TF—Tj): OVA.W Q w,,-- 0 4i <br /> Change in Reading(kr.-Rr): O <br /> Pass/Fail Threshold or �1 <br /> Criteria: (J <br /> 77 <br /> x.r x:. z�s. I+mII <br /> CO:inments—(include information on rpairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIIFICATION F T CHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the info ation contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: <br /> 1 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 />