Laserfiche WebLink
Work Order: 2248887 <br /> SWRCB.January 2006 <br /> Spill Bucket Testing Report Form <br /> Tire fium i.c intendedftr use by contractnrr p�_�fnrmir r,annual testing ofbST_cpill containment.stmerur- The compleiedfr_wm and <br /> prinlorefr from lrsLv fE(applu`uble/,slloald be provided fo rMc fuciiiA'u'.vrar'ope�rrtnr)or suhmirrul rn ih�focal rebu];tlnry ugere�" <br /> I. FACILITY INFORMATION <br /> Facility Name: ,r 9 Dale cf"testing; <br /> Facility Address: !!/7 w• Fr'e-�-"' �r���r^- 9/'�s'� <br /> Facility Contact: Phone: Z 9 YG z —/`ice <br /> Date Uveal Agency Was Notified of Tzting: <br /> Name of Local Agency Inspector(q prevent dvin3eres!mg)' <br /> 2. 'TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: fj w-' <br /> Credentials[: ❑CSLL3 Contractor KfCC Service Tech. D S WRCR Tank Tester Li Other(Spcchf <br /> LicermeNumber(s): f2yev e7-wT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Use& Pd4ydrouatic D Vacuum n Other <br /> Test Equipment Used. Ewiprrivnt Resolution: <br /> Identify Spill Bucket(By Tank 1 ®f 2 y, 3 S/ 4 <br /> Number.Storad Product,etc, !! e"� "`er ' <br /> Bucket Installation Type: :1 Direct Bury to Direct Bury G Direct Bury D Direct Bury - <br /> C-Wontained in Sum Contained in Sum 1J-cmitairc in Sump Contained"Sum <br /> Bucket Diameter: / /Z- /'� <br /> Bucket Depth: ij I?' /J. s-O I J !~O <br /> Wait time between applying / f <br /> vacuum/water and start of test: <br /> 1'est Start Time(TJ: <br /> Initial Reading(R,): f.73'r /° / a / <br /> Test End Time(Tt): /11-/i..__ itr/� /9!/j <br /> Final Reading(RF): f.7�r <br /> Test DLratica(TF-Ti): <br /> Change in Reading(Rr-R,): <br /> ts/Fail Threshold W <br /> Criteria: <br /> Test Result 3 Feel ❑Foil SPass t7 FaB 0 Pass 17 Fail <br /> Comments—(include information an repairs made prior to teatiw,and recommended follow-up fwfailed Pests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the info n allJON contained in this repot(is trwe,",mmte,and in full compliance with legal raquiremenrx <br /> Technician's Signature. e '-"" Date', <br /> State laws and regulations do not cu*Tently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br /> Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin,Texas 78759 <br />