Laserfiche WebLink
Spill Bucket Testing Report Form SWRCB,January 2006 <br /> This form is intendedfor use by contractors performing annual testing of UST spill containment structures. The completedform and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACn.1TY INFORMATION <br /> FaEaA <br /> _ Date of Testing: /_ -_ � <br /> Fa : J 5 , (C L/� Ct - <br /> Fa : VA i LL It Phone: _ <br /> Dacy WasNagencyInspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: <br /> Credentials: &CSLB Contractor rgJCC Service Tech. D SWRCB Tank Tester D Other(Specify) <br /> LicenseNumber(s): L Z L-V <br /> IV <br /> 3. SPELL BUCKET TESTING INFORMATION <br /> Test Method Used: OLHydrostatic D Vacuum 0 Other <br /> "TesCLE-quipment Used: Equipment Resolution: YICucket(By 70rCoutame7dimn <br /> 1 2 34 <br /> Product, J6 O ion Type: S Direct Bury &Direct Bury 0 Direct Bury <br /> S D Contained in Sum 0 Contained in Sum 0 Contained in Sum <br /> Bucket Diameter: /?-" <br /> Bucket Depth: 3„ <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): <br /> Initial Reading(RO: �y ` <br /> ,�WI♦ 1• �� �O �rr <br /> Test End Time(TF): 2 .0,4 <br /> Final Reading(RF): „ I <br /> Test Duration(TF-Ti): <br /> Change in Reading(RF-R,): !S " k, ®• . <br /> Pass/Fail Threshold or <br /> Criteria: Q ,Qpf' �P•` ® QHS` <br /> Test Repnk: JIM= El gso Via", 0 Fail sSLRass 0 Fail Q Pass 0 Fall <br /> Comments- include i ormation on repairs madeprior to testing and recommended ollow- or jailed tests) <br /> �JN\C cieXi L`�� T <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 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: I f - <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more skkilleat. <br />