Laserfiche WebLink
0 <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors per fortning annual testing of UST spill containment structures. The completed form and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />n e nrr irrw rATT. fl n,a A •rinAT <br />Facility Name: , 6 _ Date of Testing: <br />Facility Address: .7 cy< <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <br />7 mine+,rymi, f ni%TmuAi,1Vt) J TATP072MATMN <br />Company Name: L& e ! �• ym <br />Technician Conducting Test: A <br />Credentials: ❑ CSLB Contractor BICC Service Tech. ❑ SWRCB Tank Tester 0 Other (Spec) <br />License Number(s): <br />rr1v cmTNTf+- TNT T'� AD ftiT A'r`TnN <br />Test Method Used: <br />. Hydrostatic 0 Vacuum 0 Other <br />Test Equipment Used: <br />Equipment Resolution: <br />Identify Spill Bucket ( TaTank <br />Number, Stored Product, etc. <br />2 <br />2 <br />3 4 <br />Bucket Installation Type: <br />0 Direct Bury <br />®Contained in Sum <br />❑ Direct Bury <br />0 -contained in Sum <br />❑ Direct Bury ❑ Direct Bury <br />G -Contained in Sum 9-eontained in Sum <br />Bucket Diameter: <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test: <br />� <br />Test Start Time (Tj): <br />71_ <br />A, <br />Initial Reading (Rj): <br />Test End Time (TF): <br />Final Reading (RF): <br />Test Duration (TF — TI); <br />/ /r•. <br />Change in Reading (RF -Rj): <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />0—Pass 0 Fail <br />❑--Pass 0 Fail <br />O"Pass ❑ Fail @.-Pass 0 Fail <br />Comments — (include information on repairs made prior to testing and reconirniertded foUoTv-up forfailed 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: % — - -7 V-/ o ' <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />