COMPLIANCE INFO_2009-2010 - Laserfiche WebLink

Home Browse Search

0 0 SWRCB, January 2006 Spill Bucket Testing Report Form This form -is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Date of Testing: Facility Address: Facility Contact: Phone: Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (f present during testing): 19 COKKI►ICII7I :u: I Company Name: Technician Conducting Test: Credentials: ❑ CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) License Number(s): 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ❑ Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: Equipment Resolution: Identify Spill Bucket (By Tank 1 —72 3 4 Number, Stored Product, etc.) N Bucket Installation Type: ❑ Direct Bury I ❑ Direct Bury I ❑ Direct Bury ❑ Direct Bury II ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump Bucket Diameter: Bucket Depth: Wait time between applying vacuum/water and start of test: Test Start Time (Tj): Initial Reading (Rj): Test End Time (TF): Final Reading (RF): Test Duration (TF — Ti): Change in Reading (RF - Rj): Pass/Fail Threshold or Criteria: Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) �X CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all toe information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: Date: State laws and regulations do not currently regl'ire testing to be performed by a qualified contractor. However, local requirements may be more stringent.