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F1 <br />Y <br />v <br />SWRCB, January 2006 <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 owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Date of Testing: <br />Facility Address: <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing; <br />Name of Local Agency Inspector (if present during testing): <br />Y►, i� :: f� 1 , lz <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: Hydrostatic Vacuum Other <br />Test Equipment Used: Equipment Resolution: <br />Identify SpillBucket (By Tank 1 <br />Number, Stored Product, etc. <br />2 3 <br />4 <br />Bucket Installation Type: Direct Bury <br />Contained in Sump <br />Direct Bury Direct Bury <br />Contained in Sump Contained in Sump <br />Direct Bury <br />Contained in Sum <br />Bucket Diameter: <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TI): <br />Initial Reading (R,): <br />Test End Time (T,:): <br />Final Reading (RI.): <br />Test Duration (TI: — TI): <br />Change in Reading (RI: - R,): <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: ❑Pass -0. Fail <br />❑ Pass ❑ Fail.` Q Pass ❑Fail <br />❑Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed 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: <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 />