Laserfiche WebLink
6 <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 front tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: I Date of Testing: 8 7 <br /> Facility Address: 13 36 C 7�e A eco <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <,-- jc'-/_ <br /> Technician Conducting Test: eca f4,r <br /> Credentials': ❑CSLB Contractor C Service Tech. ❑S WRCB Tank Tester ❑Other(Specify) <br /> License Number(s)---, (0 et 2 Z - <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑Hydrostatic ❑ Vacuum ❑Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket (By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) t'e-re C <br /> Bucket Installation Type: ❑Direct Buie ❑Direct Bun ❑Direct Btux ❑Direct Bute <br /> Erforuained in Sunip ❑ Contained'ill Sunip ❑Contained in Sum ❑Contained in Sura <br /> Bucket Diameter: r <br /> Bucket Depth: <br /> Wait time beticeeu applying <br /> aeuunONater and start of test: d r <br /> Test Start Time(Ti): L1 D <br /> Initial Reading(RI): s <br /> Test End Time(TF): 1 S <br /> Final Reading(RF): ( �° <br /> Test Duration(TF-TI): lyy <br /> Change in Reading(RF-RI): <br /> Pass,,Fail Threshold or <br /> Criteria: <br /> Test Result: vpass n Fail Cl Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail <br /> Comments- (include information on repairs made prior to testing, and recommended follow�-up for failed tests) <br /> Z� '1 G I eCj L?ra I V',A I Ve �kA<� l �$--f <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: <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However,local requirements <br /> may kA mnro ctrinaAnt <br />