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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 (if applicable), should be provided to the facility owker/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: C- , e- r v;L ,q4- Lia vsc". 54 • 'J'f c � . r.4; Date of Testing: 1 <br />Facility Address: 1� G U 50 u. a v,.o- <br />Facility Contact: i tc r r)-0 ,n c a O C1 Phone: `< U' % �; > (,, — U <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (ifpresent during testing): <br />� �r+�c•rrtvr_ rntvT� � r�rnu tAT;i'It1RMATtnN <br />Company Name: ►2 i , P i '� L.•.. ^ v < t �1 <br />Technician Conducting Test:�j;- a LA v, E e, <br />Credentials': ❑ CSLB Contractor JXICC Service Tech. 'SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): :r� G if d --• ltd <br />z carr i TkTU! TZV r Tweimmr TT41PARMATMN <br />Test Method Used: Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: - p ,) E Equipment Resolution: <br />Identify Spill Bucket (By Tank 1 —1 y 14-1� s <br />Number, Stored Product, etc. )Z r? U, <br />2 -I evv lz-12- <br />;L. P , V 1 a i <br />3 ' ° `< 14'- <br />f7 e ! " <br />4 u <br />� <br />Direct Bury <br />Bucket Installation Type: ❑ Contained in Sump <br />Direct Bury <br />❑ Contained iii S2�ER <br />Direct Bury? <br />❑ Contained in Sump <br />Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />Bucket Depth: <br />Wait time between applying <br />vacuum/AVA67eDand start of test: ? r"" " ' '� cl <br />_ <br />Test Start Time (T): 16 ' 0 <br />Initial Reading (Rj): `f <br />Pv f F <br />Test End Time (TF): 1 j . <br />�D <br />Final Reading (RF): 3 ? `?f � ` <br />" (�� � F <br />3 .� �� ` ° <br />`� Y P <br />Test Duration (TF - TO: ✓t r t �'' <br />,d v� ° �- <br />s s'' �'" <br />Change in Reading (RF - RI): <br />Pass/Fail Threshold orga <br />Criteria: i Y7r En j' �� f <br />- P p c^ c.c=Y <br />? ✓ ,' ;� _ ,.s <br />E <br />Test Result: Pass ❑Fail <br />Pass 10 Fail <br />;iq Pass C1 Fail <br />ass ❑ Fail <br />Comments (include information on repairs made prior to testing, and recommended follow-upjorJat[ea tests) <br />CERTIFICATION OF TECIINICIAN <br />I hereby certify that all the inforttuadon contained in <br />Technician's <br />' State laws and regulations do not currently require testing to be <br />may be more stringent. <br />TOO 0/TOOO12 <br />is <br />FOR CONDUCTING THIS TESTING <br />accurate, and in full compliance with legal requirements. <br />Date: <br />by a qualified contractor. However, local requirements <br />U10 tfL 609 YHA TETT 600Z/9T/OT <br />