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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 owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Ctk e. (oft- -e n.. L...iQ �.�..:> r y ,� , ; , i ; (!. i ' ; Date of Testing: r,) j <br />Facility Address: C b U ;o 1a , 1 ii C I" <br />Facility Contact: h ? �� r ,(... c.! ✓� , a.� r ► Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (ifpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: ' f T fcy <• r , ,� . , �.. r n 1 <br />Technician Conducting Test: <br />Credentials': ❑ CSLB Contractor ' CC Service Tech. Q SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): O) t t) 1--, <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ` 'H drostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: 7r, > . <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 1 Am I/--'' <br />JZ,_ r°a V <br />2 -Fr,/-, <br />3 <br />4 <br />Bucket Installation Type: <br />p`Duect Bury <br />❑ Contained in Sump <br />;p Direct Bury <br />0 Contained in Sump <br />0 -Direct Bury <br />❑ Contained in Sump <br />0"Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />Bucket Depth: <br />+ <br />t' r j <br />r_I <br />f <br />Wait time between applying <br />vacuum/ ate nd start of test: <br />0 , ? ,. "' <br />"„ "r° " <br />/ "> •i <br />t . <br />Test Start Time (Ti): <br />Initial Reading (Ri): <br />13 <br />Test End Time (TF): <br />Final Reading (RF): <br />Test Duration (TF - Tj): <br />Change in Reading (RF - RI): <br />r. <br />r r r <br />45 t <br />jai <br />Pass/Fail Threshold or <br />Criteria: <br />w"' <br />Test Result: <br />d Pass ❑ Fail <br />`,Q' Pass ❑ Fail <br />Ej; Pass ❑ Fail <br />'Q -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 certto that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature:L," Date: w � '� ..w .�' <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 />