Laserfiche WebLink
Oct 17 13 08:59a Elite IV Contactors 12094616 <br />CEIV-g <br />RE <br />el (, T 1 PMOB, January 2006 <br />Spill Bucket Testing Report Flm ngL <br />ffiltN Q A <br />This formis intended for use by coniractors,performingannual testing of USTspill cor 4 nmorm and <br />printouis from tests (if applicable);shouldbe providedto the faciktyownerloperatorfr ubmincal regu atory agency. <br />1. FACILPI'Y INFORMATION <br />Facility Name: ., i;- �' ,") <br />Address: . <br />contact: J <br />1 Date Ipc4A&cncy Was Notified <br />Nanne of Local Agency Inspector <br />phone: <br />2.. TESTING CONTRACTOR INFORMATION <br />quTany Nam: _ <br />`.Teabnician Conducting Test <br />tials': O CSLB Contractor CC Setvice'I'ech 0 SWRCB Tank Tester 0 Other (Specafyj <br />Licenses idumher(s): <br />3. SPILL BIICIM TESTING INFORMAT IO) <br />TestMethod Used:. drosia& D Vacs= 00t Cr. <br />Tcst Fquipan=1 Used: t ° Eqxi anent Resolution: <br />Identify Spdi Bucket (By Tank 1 r. 2 3 4 <br />Number, Skmed Product etc '� • j ; , . _ <br />Installation Tppe: • .Id Direct Bury 0 Direr Bury E] li a^t Bury 0 Direct Bury <br />is Con b in S , 0 Contained in q (:d ,tained.in S 0 Con is <br />,f m ' . <br />B t Deptic <br />76, U _ <br />Wait firne betwem applying <br />and start of fest: _ <br />TcstSnartTime Wit) -- ._..._ .�. % - <br />Initial Reading W: S' _ <br />Test End Thm.(TF): _ <br />Final Reading (R,,): <br />Test Dm ufion (TF —.T,): <br />e snRmding (RF -+W= _ <br />PasslFali Threshold or <br />i <br />CoMmients =- (rnclude information on repairs madeLrior to testing, and recommender, ilosv-up for failed rests). <br />jr <br />e i-0-h(ula b2atr.r <br />CIERTIFICATION OF TECHNICIANRESPONSIBLE FOR CONDU 4 ING THIS TESTING <br />Y hereby certify these all the anform . n: cnntalned in' resort, is trace,. accurate, and a is "ull compliance with legal requirementx. <br />ciati's Si bate: /�✓�� / . <br />recbni gnatmr: <br />i State laws and regulations do not 'c urrently require testiag to be performed by a qualified -,x et met or. However, tocsl-requiresneats <br />may be more stringent: <br />