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Jun 20 06 10s40a Elite Iv Contractors Inc 2084616342 p. 1 <br /> 5�-w -?6 �5��x on W <br /> .set nd FAr t:/av <br /> SWRCB,January zoos <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 /> 1. FACILITY INFORMATION <br /> Date of Testing <br /> Facility Name: r-G- <br /> Facility Address: 6f -i^ roc• ,"" <br /> Facility Contact: cG°J• <br /> Date Hal Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> Z. TESTIG CONTRACTOR INFORMATION. <br /> Co an Name: <br /> Technician Conducting Test: <br /> Credentialsp 0 CSLB Contractor 7�CC alloWNWRIL 0 SWRCB Tank Tester Other(Specify) eSB�✓ <br /> License Number(s): _.;eatU'J �. <br /> 3. SPILL.BUCKET.TESTING INFORMATION <br /> Test Method Used; 0 Hydrostatic 0 Vacuum er <br /> Test Equipment Used: `oculc -� Equipment Resolution: <br /> identify Spill Bucket(By Tank 2 ,-.- 3 4 <br /> Number,Stored Product,etc. <br /> 0 Direct Bury D Direct Bury a Direct Bury D Direct Bury <br /> Bucket Installation Type: ;Contained in S Q Contained in S [3 Contained in L=M ❑Contained in S <br /> Bucket Diaxneter.. <br /> Bucket Depth: <br /> Wait tame between applying ,�® ,,�r�°7 p <br /> vacuum/water and start of test: ®7, <br /> Test Start Time(Tt): <br /> Initial Reading(R�: S, p <br /> Tcst'End Time(Tr): !/ On <br /> Heal Reading(RF): <br /> Test Duration(Tx-Tz): <br /> Change in Reading(RF-Rj): �.-r' <br /> Pass/Fail Threshold or <br /> Criteria: <br /> sgoR <br /> Comments (include information on Lgairs made prior to testing,and recommended ollow-upor failed tests). <br /> Rcrl1 ee �c�e�� b n) L7 T e�le to-e <br /> CERTIFICATFO. OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THTS TESTEI(G <br /> 1 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 G' <br /> r State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be=re stdng0t. <br />