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eSWRCB, 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 owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name:o ; Date of Testing: / S <br />Facility Address: ll 613 <br />Facility Contact:,Phone: C1q - 51 <br />Date Local Agency Was Notified of Testing: ,a <br />2.: TESTING. CONTRACTOR INFORMATION. <br />Company Name: LU tCjto <br />Teclmician Conducting Test: <br />OL <br />i <br />Credentials': 0 CSLB Contractor ' CC Service Tech. 0 SWRCB Tank Tester . 0 Other (Sped) . <br />License Numbers):.(�' <br />3. SP]Q,L RICKET TESTING INFORMATION <br />Test Method Used: , <br />drostatic Vacuum Other <br />Test Equipment UsedI <br />$quipmcnt Resolution. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product; etc: <br />1,� 2 3 4 <br />C/C <br />Bucket Installation Type:, <br />fd°Direct Bury, . ❑:Direct Bury 0 Direct Bury ❑ Direct Bury <br />❑ Contained in S ❑ Contained in 0 Contained. in S 0 Contained in S <br />Bucket Diameter. <br />Bucket Depth <br />Wait time between applying <br />vacuum/water and start oftest: <br />*Test -Start Time (T►)...._.. <br />InitialReading (Ri): <br />Test End Time.(TF): <br />Final Reading (RF): <br />g <br />.Test Duration (TF — Ti): <br />, <br />Change in Reading (RF -Rr): <br />Pass/Fail Threshold or <br />metena ...,.. /��.:.. <br />r <br />Comments,`- (include information on repairs made prior m testing, and recommended follow-up far failed tests) <br />