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SR'RCB.January 2006 <br /> Spill Bucket Testing Report Form <br /> Thisfano is intendedfaruse bvcontractorslw+ rnnng unnual testing of USTspilleonrainment.sintcmres. The completedform and <br /> prinrnurs f+•onr reva lijapplicuhlel,.chu+dd be prnridrr/m tbr'facility ou'utodoperutor_Tm-suh+uiru+l to the livid regulato'l agents•. <br /> FACILITY INFORMATION <br /> Facility Name: <br /> Facility Address: e i <br /> Facility Contact: I'honc: <br /> Date Local Agency Was NoO d of Testing <br /> Name of Local Agency Inspector(ifln-esent tbn-ing resting): <br /> 2. 1*1•:STI: 'G C 4TRACTOR INFORMATION <br /> Company Name_ _ <br /> Techmcsan Conducting est: --- <br /> Credential-:: O CSLB Contractor _ XICC Senice l'ech. 0 SWRCII 'Lank Tester C Other(Spevf, <br /> LscenseNumber(s): Jzr/�3i6- ��-uG-✓t — — - -- - <br /> 3. SPILL IIUCKF.T"1'1":STING IINFORNIATION <br /> Test Method Used: iydrosntic U Vacuum 0Other <br /> Test Equipment Used: Equipment Resolution: <br /> Iden tifySpi11Bucket (BvTank 1a 2 3T v 3 <br /> Numher, Stored Prnduct,etc.) F/,z �.rJ.u_ ' <br /> Bucket Installation Type: -Direct Bury H Direct Bury 0 Dircct Bury 0 Direct Bury <br /> >2�Contamcd in Sump ACtimained in Sump 3 Contained in Sump 0 Contained in Sum <br /> Bucket Diameter: /Z <br /> Bucket Depth: /s/ <br /> Wait time between applying - - <br /> vacuum/water and start of test: <br /> Test Start Time Cfd: O•'Oa / .,Ar- <br /> Initial <br /> DrInitial Reading(Rs): /-j" /3" <br /> Test End Time(Tr): •v-b- <br /> Final Reading(R,): <br /> Test Duration(Tr-TJ: <br /> Change in Reading(R+-Rt): Q O <br /> Pass/Fail Threshold or <br /> Criteria: 7471r` - ��- ,r 7404 /6 / <br /> Teat Reatdt: X Pan 0 Fall �Pad 0 Fall Pius 0 Fatl ❑ Pas ❑Fall <br /> Comments-(include irfornratlon nn repairs made prior to trsting, and mcommendedjnldosr-upforjailed tests) <br /> CF.RTI FI CAT ION OF TECHN IC LAIN RF:SPONS IIID"F.FOR CON U UCI'I NG•I'I I IS'I•EST ING <br /> /hereby terrify thus all the information,contained in this reporr is true,urcurare.and in fill compliance with legal reyaire�menm <br /> Technician's Signature:�l <br /> t State laws and regulations do not currently require testing to he performed by a qualified contractor.However.local requirements <br /> maybe more stringent. <br />