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10/06/2011 08:13 2099316743 <br />Nov 04 10 07:34a Elite V Contactors <br />Waterloo Food Mart <br />120946 `42 <br />#0720 P.014/015 <br />P-6 <br />SWR£"B, Iaassacy 2006 <br />SPW Bucket Testing.Report Form <br />i%s form is intended for use by contractors perfornttng annual resting of UST spi11 containment structures. rite completed form and <br />printoritc from tart, (cfapplicable), should be provided to thefacdiry ozvtterJepemtor for submittal to rhe local regulatory cogency. <br />I 'FAM17V TNMADMsqrrnrN <br />Data of Tes �. <br />_ �� yam. <br />Facility Address: r r F <br />Facility Contact. Phone: ' <br />Date Local Agency Was Noted of Testing • _ <br />Name. of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRArGnu rNPOR-NsamrnN <br />Cody Name: ; ,<z '- <br />Technician Conducting Test. �f _ <br />Credentials'. ❑ C SLB Cortmctor E1ICC Service Tech.y y 0 SWRCB Taz& Tester 0 Other (Specfjy) <br />License N=bcr(s): <br />3_ SPILL BTTCKFT TF-CTNE : YNEYlRMATION <br />Test Method Used: <br />j Lhlydrostatic <br />.0 Vacu= <br />q Other <br />Test Equtme t Used- <br />Bgnip zt Re&o11ution_ <br />Idents y Spilt Bucket (By Tank <br />lhimher. Stored Pradrrct, etc <br />1 <br />f"7 C <br />Z <br />f f <br />3 4 <br />Buckct Iris ation T <br />u Direct Bury <br />NCoutained in Su= <br />0 Direct Rury <br />G+hCoutained fn <br />0 Direct Bury D Direct Bury <br />0 Contained in SuaV 0 Contained is S <br />B*cket Diameter, <br />2 <br />a <br />-Bucket Dcptiz: <br />`t <br />rr <br />Wait time botween applying <br />Vrcli=twater =d Start of test: <br />d !2� tiw' <br />?, <br />Tcst StattTime (TO: <br />initial Reading (R): <br />Test End Time (TF)- <br />FAsal Reading (RP)'3/7,, <br />Teat Duration (TF - TO: <br />Change in Reading (RF - RI): <br />t <br />Pass/Fail Tbreshold or <br />Criteria: <br />' <br />t.olutuMU (Include information on repairs made prior to tesfing, acrd recommended followup for fat d iestTI <br />CERTMCATTON OF TE=C A.N RESPONSIBLE FOR CONDi7CT1NG TRIS TESTING . <br />I hereby certify the# all, {he in_formarloh. cont�line4 in this report is true, arcurate� and in; furl compliance jvkht legal requirements. <br />f f <br />Technician's 5igaature: Dax: J✓ j <br />r - <br />s State laws and regahtwns do not curtentlY rewire testing to bpTerformcd by a q=dZed cost•tractor. However, local requutments <br />nny be snore stngeat i <br />