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SWRCB, January 2002 <br />- r IBX rr. nriT T !+d-%TZ`T A ITTA/iW10 r Rl1XT..Q. <br />Page of <br />Commenis — (include in ornzation on re aifs made prior to testing, and recommended follow-up for failed tests) <br />Please direct any comments regarding this form to: <br />SWRCB UST Program, Atm: 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 />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: <br />❑ Spill Bucket Manufacturer <br />ndustry Standard ❑ Professional Engineer <br />❑ Other (Specie) <br />Test Method Used: <br />❑ Pressure <br />❑ Vacuum 9 -Hydrostatic <br />❑ Other (Spec) <br />Test Equipment Used: j 12 <br />Equipment Resolution f <br />Spill Box # Spill Box <br /># Spill Box # Spill Sox # <br />Bucket Diameter: <br />'' <br />Bucket Depth: <br />✓ ®` <br />Wait time between applying <br />pressure/vacuum/water and <br />starting test: <br />Test Start Time: -- <br />Initial Reading (Rj): <br />Test End Time: <br />Final Reading (RF): <br />Test Duration: <br />//z <br />Change in Reading (RF -RI): <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />Pass ❑ Fail <br />❑ Pass <br />❑ Fail ❑ Pass ❑ Fai1 <br />❑ Pass ❑ Fail <br />Commenis — (include in ornzation on re aifs made prior to testing, and recommended follow-up for failed tests) <br />Please direct any comments regarding this form to: <br />SWRCB UST Program, Atm: 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 />