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SWRCB, January 2002 0 a Page of <br />9_ CPTF.T./OVF..RF'T1.T. CONTAINMENT BOXES <br />Facility is Not Equipped With Spill/Overfill Containment Boxes ❑ <br />Spill/Overfill Containment Boxes are Present, but were Not Tested ❑ <br />Test Method Developed By: ❑ Spill Bucket Manufacturer ndustry Standard ❑ Professional Engineer <br />❑ Other (Spec) <br />Test Method Used: ❑ Pressure ❑ Vacuum I ydrostatic <br />❑ Other (Spec) <br />Test Equipment Used: Equipment Resolution `a <br />r t h?ik R i t4 k$t iS cY a? �wT$�iAKYi <br />. ' mW - r a€Sl y r kFY Sn i VI4 � (Y R 'tlffi �t +� a v9i .. 7L" <br />£lfkik P3Fr: ai k k � ".: iH a�4 <br />ggyyry, �? Spill Box # J <br />Y:7 i . Wa C PS Y <br />pill Box # Spill Box # <br />Spill Box # <br />Bucket Diameter: <br />Bucket Depth: <br />Wait time between applying <br />pressure/vacuum/water and <br />starting test: <br />Test Start Time: <br />Initial Reading (RI): <br />Test End Time: <br />Final Reading (RF): <br />Test Duration: <br />- .' <br />Change in Reading (RF -R,)* <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: bass ❑Fail <br />Pass ❑ Fail ❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Commenis — (include information on repahts made prior to testing, and recommended follow-up for failed tests) <br />Please direct any comments regarding this form to: <br />SWRCB UST Program, Attn: Scott Bacon <br />1001 "I" Street, Box 944212 <br />Sacramento, CA 95814 <br />Phone: (916) 341-5873, Fax: (916) 341-5808 <br />e-mail: bacons@cwp.swrcb.ca.gov <br />