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03/14/2016 09: 36 9163712540 BZ MAINT <br /> PAGE 06/06 <br /> Spill Bucket Testing Report Form �9B,xanuary zoos_ <br /> 17iis form is€mended for ustr by contractors performing m mual testing of UST spill corxrainmeni structures, Ae eampleted form and <br /> prinloulrfrom rests(f applicable),should be provided to thefacility ownerloperator•for submitral to the local regulatory¢gency- <br /> I- KA,MM,INFORMATION <br /> FDate <br /> y No=-- . Date of Testing; <br /> Address: `7y Contact Phonc: 2'64 (-: <br /> ocal Agency Was Notified of Testiug.: <br /> Nave of Local Agency luspectar(fprerent dtfffng tesring): <br /> ;Z, 'TESTING C40NTRACTOR INFORMATION <br /> C y Narita; <br /> Todmiciaa Cooductit s lest- c <br /> Credentials : Q CSLB Contmotoz I4�C SeXvtce Tecb. SWRCB l arak faster 0 Otber(Speci ) <br /> icat�se Nui»oerts); � CP �<K <br /> 3. SPILL RTJ0MT TESTING XWO R.MA;TION <br /> Tcst Method T-hod: ydrostatic 0 vacu= ri other <br /> Test Equipment ilscci Equipment l2tsatution: <br /> 1Edentxfy Spill I3uel:et(i y Wank I t7 ? Z 4 <br /> NcimUr,,Stored Yr¢_duct etc. <br /> Bucket Installation T)pc; k=f Bury Q bunt Bury ❑pi=t Buy O Direcct Bury <br /> C1 C ntsined in Sx 0 Contained m Saa 0 COU41 zM in$n Gl`C"taium in S <br /> uwv <br /> Sachet Dim='= 0 <br /> LCtitl=ia: <br /> et Depa. 'f <br /> time batween applying w - <br /> tm(water and stBlt of test! <br /> tart Tiaw <br /> l Reading(R)): r t <br /> End ximc(Tx): <br /> R.radzug(R.): M w� <br /> ara6on(TF-TI); y, <br /> Change in R=diag(Rp-P-7)- /l f 0 <br /> all Tbresbold or - _ - <br /> 1 - a: .. <br /> i <br /> _ a ,s <br /> Comments-�(inclade in orm on an r irs made ur>'to to Vit ,and recommended follow or ailed tests), <br /> I `- <br /> f on <br /> I <br /> CE TIIE< CATfON OF TECEMCIAN RESP <br /> ONSMLE FOR CONDUCT" C-THSS', ESTINO <br /> Z kerehv ret7ify tlrcGt all,tke-information.eontcLirterl i>x this t eparf is true,.accurate;acid toAU camFllawce wdh iGg41 reTu'reercnis_. <br /> TCLlln7ClaII'S 5` I41 r:: Date: <br /> r State laws and regulaf 0w do nat cuZreQdy.regtiire testing to be perft=d by a gmUfied contractor.Howevca local <br /> may be moz+e wr*cre�uitc>rjettts <br /> nt. <br />