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n <br />0 SWRCB, January 2006 <br />Spill Bucket Testing Report Form <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 ownerloperator for submittal to the local regulatory agency. <br />I VAd-TTTTVTNi,nRMATTON <br />ga rava..a. o 0 <br />Facility Name: co A � Date of Testing: I <br />Facility Address: r6, , [_ _� / c <br />Facility Contact: c <br />Phone: 2 <br />Date Local Agency Was Notified of Testing : ( i C> <br />Name of Local Agency Inspector (if present during testing): .1`� <br />2 TESTING CONTRACTOR INFORMATION <br />onTT T WrTOVVIV TF_QTTNC INFORMATION <br />Test Method Used: drostati Vacuum Other <br />Company Name: <br />Identify Spill Bucket (By Tank 1 2 (� I 3 C 4 <br />Technician Conducting Test: <br />ec Bur ec Direct Bury <br />rect B <br />Credentials'. SLB Contrac <br />I.CC Service Tech. SWRCB Tank Tester Other (Specify) <br />License Number(s): _ <br />( S Cl <br />onTT T WrTOVVIV TF_QTTNC INFORMATION <br />Comments- (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFITCATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the i on contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: Date: --Ll- - 2 �i -0 r� <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 />Test Method Used: drostati Vacuum Other <br />Test Equipment Used: o - J- ." r Equipment Resolution: <br />Identify Spill Bucket (By Tank 1 2 (� I 3 C 4 <br />Number, Stored Product, etc. I <br />ec Bur ec Direct Bury <br />rect B <br />Bucket Installation Type: <br />Contained in Sum Contained in Sum Contained in Sum Contained in Sum <br />Bucket Diameter: <br />�. t <br />Bucket Depth: G, <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />Initial Reading (Ri): S Cry? <br />`i 0 <br />Test End Time (Ti:): <br />0 <br />Final Reading (R,-.):&0) <br />c ' <br />Test Duration (TJ: - T,): j) t�✓i ' ,e <br />Test <br />(��w� ; ` �'t <br />Change in Reading (Rr. -'1 Rj): <br />Pass/Fail Threshold or <br />Criteria <br />Q�.jTj�(txxCC..j � <br />x ,� � <br />Fail: <br />Comments- (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFITCATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the i on contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: Date: --Ll- - 2 �i -0 r� <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 />