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i <br /> SWRCB,January 2006 <br /> ) <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The co ple d for and <br /> printouts from tests(f applicable),should be provided to thefacility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Date of Testing: �£?"7' <br /> Facility Name: <br /> Facility Address: r <br /> Phone: <br /> Facility Contact: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency inspector(if present during testing): « <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: <br /> Credentials': CSLB Contractor iCC Service Tech. D SWRCB Tank Tester D Other(Spec) <br /> License Number(s): S[� t lC �Z <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Wrostatic D Vacuum ❑Other Y <br /> Test Equipment Used: �vt tr e+� ^' <br /> Equipment Resolution: r Cdd t <br /> ^r 4 <br /> Identify Spill Bucket(By Tank 1 �� 2 3/ �fY'�f <br /> Number,Stored Product, etc. <br /> uect Bury iZDirect Bury DOirect Bury ❑Direct Bury <br /> Bucket Installation Type: �ontained in Sum ❑Contained in Sum D Contained in Sum ❑Contained in Sum <br /> Bucket Diameter: ' <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Til: !I c�.r S ✓'� <br /> Initial Reading(Ril: <br /> Test End Time(TF): c r <br /> Final Reading(RF): <br /> Test Duration(TF—Til: e� <br /> Change in Readmg(RF-R): <br /> Pass/Fail Threshold or 1 L ) <br /> Criteria: / <br /> Test Result: Pass ❑Fail ❑ Pass ❑Fail <br /> Pass ❑Fail Pass ❑Fail <br /> Comments (include information on repairs made prior to testing and recommended follow-up for jailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> hereby certify that all the info all contained in tl report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: <br /> ' State laws and regulations do t c ently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />