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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(if applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Skj( Date of Testing: 7 <br /> ,Ze 16�i- <br /> Facility Address: n1PVSF- SOL <br /> Facility Contact: Mdc-e- 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 ame: am� L <br /> Technician Conducting Test: <br /> Credentials): 0 CSLB Contractor 1+16C Service Tech. 0 SWRCB Tank Tester 0 Other(Specify) <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: 9-gy-drostatic 0 Vacuum 0 Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) —) - I g 1-�2 1 <br /> Bucket Installation Type: 0 Direct Bury 0 Direct Bury 0 Direct Bury 0 Direct Bury <br /> 0,C-ontained in S!mp 4C&-tained in Surnp El Contained in Sump El Contained in Sump <br /> Bucket Diameter: <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: h V, <br /> Test Start Time(Ti): <br /> Initial Reading(R)): <br /> Test End Time(TF): <br /> Final Reading(RF): <br /> Test Duration(TF-TI): h <br /> Change in Reading(RF-RI): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: P-0-ass 11 Fail Rr-'Pass 0 Fail 0 Pass 0 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: <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />