Laserfiche WebLink
Spill Bucket Testing Report farm <br />This form is Intended for use by contractors performing annual testing of UST spill containment structures. The <br />printouts from tests Of applicable), should be provided to the facility owner/operator for submittal to the local r <br />1. FACILITY INFORMATION <br />Facility Name: Date of Testing: _ a <br />Ftwility Address: } <br />Facility Contact: phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector ffpresent during testing): —.k, t rr <br />4 <br />n <br />n <br />January 2006 <br />t form and <br />agency- <br />Bury <br />gency. <br />B to in <br />aed <br />❑ Fail <br />CERTMICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />1 hereby certify that all the information contained in this report is true arrurrrte, and iri full cornpllunce with legal requtrments. <br />Technician's Signaure: <br />Date: <br />State laws and regulations do not currentl <br />y require testing to be performed by a qualified contractor. Howcvvj, Iocal re <br />may be morestringent. erfd uiremenls <br />99/90 139yd (100A Sr9 340 V. 9L9L6C8G0Z bZ:9T ZTGZ/TC/ZT <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: U.S.T. <br />Compliance Testing Inc. <br />Technician Conducting Test: <br />Tony Fontana <br />Credentials': x CSLB Contractor x ICC Service Tech. 0 SWRCB Tank Tester ❑ Other (Specifi)) <br />Liecnsc Nun]tiGi(j}: 846288 <br />10164273 -UT <br />3. SPILL BIICKET TESTING INFORMATION <br />Test Method Used; <br />x Hydrostatic ©Vacuum Other <br />Test lrquiptnent Used <br />L-quipment Resolution: <br />IdSpill Bucket (By Tank <br />1 3 <br />Number, Stored Product, etc.""1�i <br />l <br />Bucket Installation Type; <br />PFDirect Bury Direct Bury El Direct Bury <br />Buoket Diamctcr: <br />❑ Contained in Sum ❑Contained in Seim Contained in Sum <br />Bucket Depth: <br />r } n <br />G <br />fit Li " <br />Wait time betwo#n applying <br />vacuum/water and start of test: <br />Q <br />Test Start Time (Tj: <br />Initial Reading (Ro: <br />�l , <br />Test End Time (TO.- <br />� <br />FiDA' Reading (RF): <br />1 <br />Tost Duration Cr, 1 F — T�): <br />` <br />Change in Reading (RF - Ri: <br />rass/Fail Threshold or <br />Criteria- <br />Test Rtsult: <br />COtljm�IltC <br />GC Pass ❑'"ail iP''Pass 0 Fail ❑ Pass- C]Fail <br />— (incluria informa7tion on re airs made Prior to testin , and recommended follow -u for ailed <br />4 <br />n <br />n <br />January 2006 <br />t form and <br />agency- <br />Bury <br />gency. <br />B to in <br />aed <br />❑ Fail <br />CERTMICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />1 hereby certify that all the information contained in this report is true arrurrrte, and iri full cornpllunce with legal requtrments. <br />Technician's Signaure: <br />Date: <br />State laws and regulations do not currentl <br />y require testing to be performed by a qualified contractor. Howcvvj, Iocal re <br />may be morestringent. erfd uiremenls <br />99/90 139yd (100A Sr9 340 V. 9L9L6C8G0Z bZ:9T ZTGZ/TC/ZT <br />