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002198 <br />SWRCB, Tanuary 2606 <br />Spill Bucket Teeing Rep®rt Form <br />Aliform Is bntendedfdr use by contractors performing annual testing of UST spill contatment structures. The completed farm and <br />printouts from tests (if applicable), should be provided to the faculty ownerloperator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Nemo sea Date of Testing - <br />Facility <br />Facility Address: c}/- 4'! 3' <br />Facility Contact: Phone: <br />Data Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (tf'present during tesftno: <br />2. TESTING CONTRACTORMFORMATION <br />lmpany Nanw, <br />-,chnician Conducting Testi <br />edendalai 0 CSLB Contractor p1CC Service Tech ❑ SWRCB Tank -Tester 0 Other (SPecify) <br />Cense Number(s): <br />TING INFORMATION ' <br />Test Method Used: <br />3. SFILI. BUCKET TLS <br />drostatie ❑ Vacuum 0 other <br />'fest Equipment used: <br />Equipment Resolution: <br />Uri <br />1 <br />Q Direct Bury <br />Mfontained in Snm <br />2 <br />❑ Direct Bury <br />i entwined in Sum <br />3 <br />0 Direct Bury <br />M-E-ontained in Sum <br />4 <br />O Direct Bury <br />9-Gontained in Sum <br />Id=fy Split Bucket (By Tank <br />Niamber, Stored Product, etc. <br />Bucket ins on Type: <br />Bucket Diameter: <br />Bucket Depth: <br />Wait time between applying <br />vaeuum1water and start of test: <br />>> <br />p <br />Test Start Time (Ti): <br />Initial Reading(&): <br />TeseEnd Time (T,,): <br />Final Reading (R* <br />Test Duration (Ta— TD: <br />l 1x:-- <br />a - <br />Change in Reading (Ry -U: <br />Pass/Fall Threshold or <br />Criteria: <br />Tit R: <br />mass i7 Fail <br />(]-!Pass ❑Bair <br />Eii�ass ❑ Fail <br />a -.Pass Q frail <br />Comments (include hybrmadon on repairs made prior to tes� and recommeflaeQJ0it 1B -u or uum f"44 <br />CERTIFICATION OF TEMICIAN R&SPONSIBLE FOR CONDUCTING THIS TESTING <br />X hereby certify that all the inforimttlon contained in this report is true, accurate, and to ftU compliance with 1e9a1 requirementR <br />r� f� <br />Technician's Signature; 'G Dom: <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 />