Laserfiche WebLink
Jan 15 15 08:21a Elite Iv Contractors Inc 2094616342 p.3 <br /> F\7 CB,January 2006 <br /> Spill Bucket Testing Report Forane <br /> 77tisforot is inl(.7tded for use by contractors performing annual taming of UST spill contaiamanr structures.The completed form and <br /> printaulsfrom tests(tfapplicable);should be provided to thefaciliry owner/operator forsubmittal to the local regulatory agency. <br /> I. FACZnY.INFORMATION. <br /> Facility Name; , ) Date of Testing: <br /> Facility Addrces; -.' <br /> -)( Facility Contact: '@ Phone: <br /> "Date Local Agency Was Notified of Testing: <br /> �{. Name of Local Agency Inspertor f fpresentduring testing): <br /> 2. TESTING CONTRACTOR INFORMATION. <br /> Company Nainc: ;" <br /> Technician Conducting Test <br /> Crctlmtialsu: 0 CSLB Conhactor CC Service Tcch 0 SWRCR Tank Tester . 0 Other(Speotf <br /> • ;License Nnmbcr(s); !c-Z;�;'i�..7�1 <br /> 3. 10,L a¢T)CKET TESMG.INFORMATION <br /> TcstMethod Used: static p Vacuum Q Other <br /> Test Equipment Used:(1,�j Equipment Resolution: <br /> Identify SpM Bucket(By Tank I 1----�� 2 3 4 <br /> Mmber,StonedProduct' % <br /> Bucket lnstaRation Type: irect IIury 0 Direct Bury 0 Direct Bury 0 Direct Bury <br /> 0 Contained in Sum 0 C.otttained in&%MP 0 Cootained.in Sb ❑Contained in Sum <br /> Bdaket DlatneteC <br /> Bticket Dcptltc /o/ <br /> Wait time between applying <br /> vacuumiwater and start or test: <br /> ,Yost Start Time(1'a) 3 <br /> Initial Reading(RI); <br /> Test Fd Ti..(Tr): <br /> Final Reading(RF): <br /> Test Duration(Tp—Tu): 1,✓ <br /> Change in Reading(Rr-Rt): <br /> Pass/Fail Threshold or > <br /> r <br /> C0MM eRtS, mclude in ormars art re fn made rias to iesrirs,mrd reeotitrnended allow or ailed tests. <br /> lv�� lz c�cl t�� htr(tyrcell— Rum t4t-� 7S11 -jj�Dhrc1 <br />