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Aug 19 11 10:20a Elite IV Contactors 12094616342 �,..;,.;., p.2 <br />S«TRCB, January 2006 <br />Spill Bucket Testing Report For i -i AUG 19 2011 <br />This form is intended for use by contractors performing annual testing of UST spill cont 7; i•r:ent structurdi,''MKOmkWye4f ti and <br />printouts from tests (if applicable), should be provided to thefacility owner/operator fo* s i=ittal to the locW1Mk0dlt00i49Cncy. <br />1. FACILITY iNFOPJ ATION <br />Facility Name: `' ( C Dz� <br />Facility Address: <br />Facility Contact '� t�` 1C uc Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): m CL iI('t <br />It of Testing: 3 / <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: r 7 ;r• <br />Technician Conducting Test: {—���•� �_�,• l _ <br />Credentials: Q CSLB Contractor WCC Service Tech. 0 SWRCB Tank Tester _ :I Other (Specify) <br />License Number(s): (p %UO �`6, /tr 6 (', - /D, Nly 2 <br />3. SPILL BUCKET. TESTING INFORMATIOD <br />❑ ydrostatic Q Vacuum ❑ L;tl <br />Eqr: it � <br />Test Method Used: <br />Test Equipment Used: <br />Identify Spill Bucket (By Tank 1 � 2 3 <br />Number, Stored Product; etc. <br />Bucket Installation Type: <br />,('Direct Bury <br />❑ Contained in S <br />❑ Direct Bury <br />❑ Contained in <br />❑ I, <br />Q C <br />Bucket Diameter: <br />Bucket Depth <br />,, <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TO: <br />Q AM <br />Initial Reading (RI): <br />S l <br />Test End Time (TF): <br />AM <br />Final Reading (RF): <br />151/31- <br />Test Duration (TF — TO: <br />Change in Reading (RF- RF): <br />Pass/Fail Threshold or <br />Criteria: <br />t JG y <br />l o <br />EM <br />ComMentS —.(include informatiA �n repairs made prior to testing, and recommende,,'j 1�ow-upjorjailedtests). <br />a <br />CERTIFiCA' <br />I hereby certify that all the <br />Technician's <br />TECffiVICLAN RESPONSIBLE FOR CONDUC "ING THIS TESTING <br />an contained initis-se�wrt-isi�ue, accurate, and ft. X411 compliance with legal requirements <br />Date: <br />State laws and regulations do not currently require testing to be performed by a qualified. o aiiactor. However, local requirements <br />may be more stringent. <br />