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0 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use ab contractorsshould be performing <br /> rovided to the fac liting of UST Spill ty o ner/operator forasubmitttal ocures. The he local regulatory agency.and <br /> printouts from tests(if applicable), P <br /> 1. FACILITY INFORMATION Date of Testing: 6 yb <br /> Facility Name: %/ <br /> st` <br /> kName <br /> Address: O W phone: <br /> Contact: <br /> al Agency W as Notified of Testing: L s <br /> Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: pn -to /I V Jrb e H <br /> Technician Conducting Test: mK eci <br /> Credentials: CSLB Contractor CC Service Tec . SWRCB Tank Tester Other(Sp fy) <br /> License Number(s): � <br /> 3. SPILL BUCKET TESTING INFORMATION L a <br /> Hydrostatic Vacuum <br /> Test Method Used: y Equipment Resolution: <br /> Test Equipment Used: eQ m' Pe �K .... <br /> Identify Spill Bucket(By Tank 1 (JQ Sup <br /> Number,Stored Product, etc. �j et ect B <br /> rContaine <br /> Bucket Installation Type: in <br /> ontaine in um <br /> Bucket Diameter: <br /> L <br /> Bucket Depth: 1,141 <br /> � <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> f <br /> Test Start Time(Ti): r 2 r J J <br /> 1 <br /> Initial Reading(R,): H !f � <br /> Test End Time(TF): Z or <br /> Final Reading(RF): Z/�o r N QQ yati N v •►vim <br /> Test Duration(TF—TO: <br /> Change in Reading(RF-Rt): <br /> Pas ail Threshold or <br /> Criteria: —(include information on repairs Pass Fat1 ass Fail ss ]tail <br /> T-tst Rem&: Pass Fat1 <br /> CIIirs made prior to testing, and recommended ollow-up forfailed tests) 1 <br /> s a edt e rt 5 G✓Cn N //f <br /> h nr /'e h V�7 ✓, <br /> F TECH JCIANNONSIBLEFOR CONDUCTING THIS TESTING <br /> I here:a :'t:ur4 <br /> anon co ireport is true, accurate,and in full compliance with legal requirements. <br /> Date: <br /> —Vt LaIJ <br /> Techn <br /> State laws and regulations durre tly require testing to be performed by a qualified contractor. However,local requirements <br /> may be more stringent. <br />