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Jun 01 07 09: 23a Elite Iv Contractors Inc 2094616342 p. 2 <br /> SwRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> Jhis form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printous from tests(if applicable),should be provided to thefacility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACE TTY INFORMATION <br /> Facility Name, Date of Testing: $-- <br /> Facility Address: r < , ice• <br /> Facility Contact Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency inspector(ifpresent during testing): <br /> 2. TFSMG CONTRACTOR INFORMATION <br /> Company Name: e? `I ,L <br /> Technician Conducting Test C•! ,� <br /> Credentials': 0 CSLB Contractor 0 ICC Service Tech. D SWRCB Tank Tester 0 Other(Spac6) <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ydrostatic 0 Vacuum 0 Other <br /> Test EquipmentUsed:- - - Equipment.Resolution: <br /> Identify Spill Bucket(By Tank 1// 2 3 4 <br /> Number,Stored Product,etc: x// <br /> Bucket Installation Type: irect Bury ❑Dired Bury 0 Direct Bury 0 Direct Bury <br /> 0 Coutained in Sum 0 Contained in S O Contained in Sump. 0 Contained in Sump <br /> Bucket Diameter. 7 , <br /> BucketDepthi <br /> Wait time between applying .. .: . ... . _ <br /> vacuum/waterand start oftest <br /> Test Start Time(Tr): 2 <br /> Initial Reading(Rt): 912 <br /> Test End Time(Tr)= 3; C-�' <br /> Final Reading(RF): <br /> Test Duration(TF—Tt): O L•e' /Ci//� <br /> Change in Reading(RF-Rt): <br /> Pus/Fail Threshold or <br /> Criteria: <br /> _ _. <br /> Comments—rinclude information on repairs made prior to testing and recommended follow-up forfailed test!) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certify.that allthe informationconfained inthis,report is true,.accurate,and in full compliance."Wir legal req t ireements. <br /> Technician's Signature: Date: <br /> r 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 />