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ii LL�L4 <br /> V <br /> N om 1 5 2009 SWRCB,January 2006 <br /> OI <br /> Spill Bucket Testing Report F NNIENT HEALTH <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 fiod -evz) Date of Testing: f El <br /> Facility Address: <br /> ,,#2 <br /> Facility Contact: KvL vi a.� f Vk'! Phone: (-Ze),l <br /> Date Local Agency Was Notified of Testing^J $7ja 71,9 ,1' K- Zr-k, <br /> Name of Local Agency Inspector(rfpresent during testing): C/Iuj� <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: 1 )l t2 T,�Y i,4 - <br /> V <br /> Technician Conducting Test: 13e,,fEL#! If e et <br /> L"IN24 <br /> Credentials: 0 CSLB Contractor", ICC Service Tech. WRCB Tank Tester 0 Other(Specify) <br /> License Number(s): -112--e-) <br /> 3. SPELL BUCKET TESTING INFORMATION <br /> Test Method Used: Z-Tkdrostatic 0 Vacuum 0 Other <br /> Test Equipment Used: —16f pe [A e ,f,I f 4"o- Equipment Resolution: 7 f2 <br /> Identify Spill Bucket(By Tank 1 Ic 4,4- 2 -r-cwt 1(77 3 V--4T 3 <br /> Number, Stored Product, etc. 9-1 'D C Se 0 irect Bu <br /> L- <br /> )Y,Dry 91)irect Bury i <br /> "rect Bury � ry <br /> Bucket Installation Type: irect Bu <br /> 0 Contained in Sump 0 Contained in Sump 0 Contained in Sum <br /> p 0 g2ritained in S/n,p <br /> Bucket Diameter: <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/ a-ier" d start of test: <br /> Test StartYi-me(T,): -3:5 <br /> Initial Reading(111): <br /> Test End Time(TF): 9- r 40 <br /> Final Reading(RF): <br /> 13 <br /> Test Duration(TF-Tf): 0 !,k o v <br /> Change in Reading(RF-Rt): <br /> Pass/Fail Threshold or <br /> Criteria: 1 ,14 <br /> Test,Result: Pass D Fall, ss 0 Fall 0 Fail 0 Pas <br /> 21-'Pa ss 3 OF I <br /> Comments-(include information on repairs made prior to testing and recommended fallow-up for failed tests) <br /> L' -1 <br /> If , ®w <br /> ? o o a <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the Information co I his report Is true,accurate,and In full compliance with legal requirements. <br /> .......... <br /> U <br /> Technician's Signat � 7t7,-. --- Date: <br /> 0 <br /> State laws and regulations do not currently require testing t/be performed by a qualified contractor. However, local requirements <br /> may be more stringent. <br />