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iye to <br /> j' <br /> y . e <br /> 1 , t <br /> . t 1 <br /> a , sa• a s...sa t <br /> ..a '-.by a + . ♦• q. %`L k { s; / t ; • dx:, "F' s, a <br /> i <br /> 146 <br /> SWRCB,7anuW2006 <br /> Sp ff*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 /> printouir from tests(if applicable),should be provided to thefacility owner/operator for submittal to the local regulatory agency. <br /> Facility Name: __ _: . <br /> 1. FACHMT.INFORMATION <br /> Date of Testing: <br /> I~aczimt�Address:. <br /> - - <br /> Facility Cofact _ <br /> - - _ <br /> Pone: _ _... <br /> Date Local Agency Was Notified-of Testing <br /> Name of Local Agency Inspector(ifpresent during iesting): <br /> 2, 'TESTINGCONTRACTOR INFORMATION <br /> Company Name' <br /> Technician Conducting Test Qa(dG� r 1AG. <br /> Credentials':_ CI.CSLB Contractoz ICG Service Tech SWRCB Tank Tester . Q Other(Specify) <br /> a <br /> :License Number(s), • . , <br /> SPU LL BUCKET TESTING INFORMATION <br /> Test Method Used: , 0 PI drostatic 0 Vacuum- Q.other <br /> 'Test EquipmentUsed: FquipmentResolution: <br /> Bill <br /> IdentifySp�l`7uckeTank Tank' `1 2 3 <br /> 4 <br /> Number,Store ,, <br /> Bucket Installfl Direct Bury Q:Direct Bury ❑Direct Bury DirectBury❑Contained m S ❑Contained ia: 0 Contained in SJO <br /> D Contained in S <br /> Bucket Di=eter- <br /> Bucket <br /> iameter y° U <br /> Bucket Depth <br /> Wait time between applying <br /> vacuum/water and start oftest t J <br /> Test Start TimierM <br /> __ �. <br /> Initial Reading,W: a --- - — — <br /> Test ftd Tmie:(TF)c Q <br /> Final Readin (R 1 n <br /> Telt DurataOII.F+F-.T : <br /> Change-in Reading(RF-R�: <br /> Pass/Fail Threshold or <br /> MIN <br /> Ct3mments. rnelude informatio 'on repaft made prior to testing and rec ommended follo*: for failed Pests) <br /> CERT? ICA '9 NOF TE 'EMCIAN RESPONSIBLE FOR CONDUCTING TBISTESTING ' <br /> ---_-_-- I hereby cert' that►�r711he.in rraation:con ed in: ".report is true,accurate.and full coon s�Iiancc N,&k Ie�a!requirement. -- <br /> Technician's Signature: <br /> Date.— /2 <br />