Laserfiche WebLink
v , <br /> 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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FFacility <br /> : -7 o v Date of Testing: �� 1 <br /> ess: k /� ( �r�llku <br /> ct: C C ! Phone: 2 S - `� 2 <br /> gency Was Notified of Tes •l Agency Inspector(if present during testing): i ct <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: C- ,� y� j �'E ,� i%1✓c G_, ^ y� Ga c <br /> Technician Conducting Test:. f2 e - G! � -z- <br /> Credentials': ❑CSLB Contractor -Service Tech. ❑SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 1.iOlsw(,I - S? "- 4` 1 q k <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: R ostatic ❑Vacuum ❑Other <br /> PBucket <br /> uipment Used: �ti a �.2 N� S , e- Equipment Resolution: <br /> Spill-Bucket(By TankFS4)ife-ct <br /> 7 , , 2 S 3 4 <br /> , Stored Product, etc. F f 1 <br /> Installation Type: Bury rect Bury ❑Direct Bury ❑Direct Bury <br /> ❑ ontained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 144 J( r 5 '/ <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): q ' H <br /> Initial Reading(RI): i t 16 A y <br /> Test End Time(TF): t v 4i S 1 C ° S 5 <br /> Final Reading(RF): -z- <br /> Test Duration(TF-TI): <br /> Change in Reading(RF-RI): <br /> Pass/Fail Threshold or <br /> Criteria: h r <br /> ...:: Fail <br /> TestRe§uIt <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> vt ,�J"a <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: ` Date: e' <br /> ' State laws and regulations do not curre tly require test'nFtobeerformed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />