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Jul 20 07 08s43a Elite Iv Contractors Inc 209461c342 p. 3 <br /> �3 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This forth is intended for use by contractors performing annual testing of UST spill containment structures.The completed form and <br /> printouts from tests ff applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency_ <br /> 1. FACELM.INFORMATION <br /> Facility Nan u + Date of Testing: <br /> Facility Address: -7s GgAvlyr Lr-L) <br /> Facility Contact; Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Nance of Local Agency Inspector(if present during testing): 2:C A E7-L6- --JqI#a <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ' <br /> Technician Conducting <br /> Credentials': 0 CSLB Contractor 0 ICC Service Tech. D SWRCB Tank Tester 0 Other(Specify) <br /> .License Number(s): <br /> 3. SPU L BUCKET TESTING INFORMATION <br /> Test Method Used: . 0 Hydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 14 l fj 2 3 a <br /> Number',Stored Producte <br /> , tc. { <br /> Bucket Installation Type:. t Bury 0 Direct Bury O Direct Bury 0 Direct Bury <br /> 0 Contained in S 0 Contained in S 0 Contained in S 0 Contained in S <br /> BucketDiameter: <br /> Bucket Depth: <br /> Wait face between applying rp <br /> vacuumlwater and start of test: J <br /> Test Start Time(Tt): <br /> Initial Reading(RO: <br /> Test End Time(TF): 1c). <br /> Final Reading(RF): <br /> Test Duration(TF—Ti): <br /> Change in Reading(RF-Rx): f, <br /> Pass/Fail Threshold or <br /> Criteria: <br /> r <br /> Comments—(include information on repairs made prior to testing,and recommended follow-up for failed tests) <br /> CERTIFICA N OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THI'S TESTING <br /> I hereby certify that all the formation.contained inthis report istrue,accurate,and in full compliance with legal requirements. <br /> Technician's Signattrr . Dates <br /> a State laves and xegulati ns do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />