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0 0 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intenm test ed for use by contractors per annual testing of UST spill containment structures The completed form and <br /> printouts front tests(i f applicahle), should he provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: <br /> Facility Address: ( ' Date of Testing: '? <br /> c� Q cT`c et r <br /> Facility Contact: <br /> Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> ETechnician <br /> : <br /> ducting Test: zy <br /> U CSL) Contractor CC Service Tech. ❑SWRCB Tank Tester 0 Other(Specify) <br /> (s): s' Z <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> EildenutySpill <br /> d: drostatic ❑Vacuum <br /> Used: Other <br /> Equipment Resolution: <br /> cket (tty Tank 1 2Product, etc.) 3 4 <br /> Bucket Installation Type: O D rect BiuA ❑Direct Bute Q D' eel Bun' <br /> .ontained in Sum Aired Bute <br /> Bucket Diameter: 1 t , ontained in Suut outailted ut Stun Q Contained in Suttt <br /> Bucket Depth: 1 =t <br /> Wait tithe betiveen applying _ l 16 f <br /> t acuunt/ ater and start of test: ( r"A /0 <br /> Test Start Time(T,): q0 �- <br /> Initial Reading(Ra): _. f r ( e . e e <br /> Test End Time(TF): f <br /> Final Reading(RF): ( .r <br /> Test Duration(TF-TI). c 70 <br /> Change in Reading(R,:-Ftz): r <br /> RissiFail Threshold or <br /> Criteria <br /> Test Result: Puss f)FailfVPass Q Fail F, Pass 1W Fail 0 Pass 0 Fail <br /> Comments— (include--information on repairs made prior to testing and recommended follow up for failed tests) <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: 12,- 9 -06 <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However,local requirements <br /> Maar ho Mnrr+etrinonnt <br />