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SWRCB, January 2006 <br /> Spill Socket 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 /> printoutsfrom tests(if applicable), should be provided to the faciItty own erioperator for submittal to rhe local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: GDate of Testing: - 7 -0 <br /> Facility Address: 2 t Y 7 m dNJ e Ala r, c c! <br /> Facility Contact: p }t,` Phone: <br /> Date Local Agency Was Nofified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Champion Precision Testing Inc. <br /> Technician Conducting Test: Zat S Tr2�r�lS <br /> Credentials': 0 CSLB Contractor [x] ICC Service Tech. 0 SWRCB Tank Tester 0 Other(Specify) <br /> License Number(s): rz S 0 <br /> LLT- <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used; [x] Hydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used: Caldwell Level Change Indicator Equipment Resolution: .0025' <br /> Identify Spill Bucket(3v Tank I 23 4 <br /> Number, Stored Product, etc.) e9 4 I <br /> Bucket Installation Type: irect Bury irect Bun _ irect Btu} ❑Direct Bun <br /> 0 Contained in Sum 0 Contained in Sum E.Coutained in Sualp 0 Contained it, Smu <br /> Bucket Diameter. <br /> Bucket Depth: /3 13 LS <br /> Wait time bemeen applying <br /> tecnuntl»eter and start of test: (V iw % /L <br /> Test Start Time(T�: p /000 (U U <br /> Initial Reading A): 12. / Z " 12-t' <br /> Test-End Time CFF): O 0 0 16.70 ! 00 <br /> Final Reading(110: 2' 2 ' ` J 2 11 11 <br /> Test Duration(TF-Tt): -70 rr"t U <br /> Change in Reading(RF-Rr) E}- <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: YPass 0 Fail Pass 0 Fail Pass C Fail 0 Pass 0 Fail <br /> Comments- (include information on repairs made prior to testing and reconmtended follow-up for failed tests) <br /> CERTIFICATION OF TECE ICIAN 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: Date: 1/ - 12 -U <br /> I State laws and regulations do not currently tegtrim testing to be performed by a qualified connector.However,local requirements <br /> m.„,jw mop";r et�t <br />