Laserfiche WebLink
0 0 S WRCB,January 2" <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 owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: W ' ! v Date of Testing: 1 a i o? <br /> Facility Address: 1;--6o. u7c WTz�crad q:si��Z_c�_ <br /> Facility Contact: ,�,,"K�c Phone: 9 c,cl —r?-zz - -3 <br /> Date Local Agency Was Notified of Testing : /c)%S/e`7 <br /> Name of Local Agency Inspector(rf present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Champion Precision Testing Inc. <br /> Technician Conducting Test: Alvin L_ Milburn <br /> Credentials'-. ❑CSLB Contractor [x]ICC Service Tech. u SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 0878949-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [x]Hydrostatic L1 Vacuum ❑Other <br /> Test Equipment Used: Caldwell Level Change Indicator Equipment Resolution: .0025" <br /> Identify Spill Bucket(By Tank l 2 w 3 tt c 4 <br /> Xurnber, Stored Product, etc.) '� q t <br /> Bucket Installation Type: irect Bury nirect Bury 56irect Bury ❑Direct Bury <br /> ❑ Contained in Sump Contained in Sump 0 Contained in SRTp ❑Contained in Sum <br /> Bucket.Diameter: t Z r 2 <2 <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T): <br /> Initial Reading(RI): <br /> Test End Time(TF): <br /> Final Reading(RF): <br /> Test Duration(TF—TI). <br /> Change in Reading(RF-Rj): <br /> Pass/Fail Threshold or <br /> Criteria <br /> Comments—(include information on repairs made prior to testrn , and recommended follow-up far failed tests) <br /> /4kL_ ,rcC—'- N 17 <br /> ,p��,shZ /V�D5 /4 `C7 ` J2 w q r_L,Z t E r� N t/ -- <br /> �1i~� Ac�� <br /> �e .�c..+c�c'►� .�� �� � �� �.�-�S �� NQ's- !�� t] <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:_ <br /> 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 />