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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(:f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Date of Testing: -S Z?�o <br /> Facility Address: 3Z C S�c .✓ �'-rl, <br /> Facility Contact: [ Phone: 20 <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: Gettler-Ryan Inc. <br /> Technician Conducting Test: Pete Garcia <br /> Credentials': ❑CSLB Contractor X ICC Service Tech. C SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 5300833-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ,-Hydrostatic ❑Vacuum C Other <br /> Test Equipment Used: 49, Equipment Resolution: ` 7e, <br /> Identify Spill Bucket(By Tank 1 t 2 kkv- 3 4 <br /> Number, Stored Product, etc) ��7wr,sre T-1 TZ-J AI�J $ 7--3 IT/ <br /> Bucket Installation Type: ❑ Direct Bury ❑ Direct Bury C Direct Bury C Direct Bury <br /> 2-Contained in Sump 8 Contained in Sump 2<ontained in Sump stained in Sump <br /> Bucket Diameter: Z '' 1-71, /Z ' 1Z'' <br /> Bucket Depth: 1z Z <br /> Wait time between applying <br /> vacuum/water and start of test: / ,, /S" „J S� �.✓ /s <br /> Test Start Time(TO: 3 ; S 3 ; s t 3:51 Iain <br /> Initial Reading(RO: <br /> Test End Time(TF): :S `/ <br /> Final Reading(RF): s 7 •,� 0 3 <br /> s <br /> Test Duration(TF-TO: Iw� <br /> Change in Reading(RF-RO: ±0 +o v f O <br /> Pass/Fail Threshold or 0O Q <br /> Criteria: <br /> Teat Result: XPass ❑Fall Pass ❑Fail Pass ❑Fail 7 Pass ❑Fail <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I 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: - - L2-D 9 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />