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Nov 04 10 07:34a Elite -V Contactors 120946'71342 p.6 <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended four 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 MORMATION. <br />Facility Name: , , _ (� Date of Testing: AZ' <br />Facility Address: f.::, ., <br />Facility Contact: Phone: C -,J <br />Date Local Agency Was Notified of Testing: <br />Name. of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Co an Name: <br />Technician Conducting Test: <br />Credentials': ❑ CSLB Contractor E11CC Service Tech.v 0 SWRCB Tank Tester 0 Other (Spec) <br />License Number(s): <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />E Hydrostatic <br />❑ Vacuum <br />11 Other <br />Test Equipment Used- <br />Equipment Resolution. <br />Identify Spill Bucket (By an <br />Number, Stored Product, <br />1 <br />2 a + , <br />3 4 <br />Bucket Installation Type: <br />0 Direct Bury <br />flContained in SuuV <br />❑ Direct Bury <br />Wfontained in Sump <br />0 Direct Bury 0 Direct Bury <br />❑ Contained in Sump ❑ Contained in Sump <br />Bucket Diameter- <br />iameterBucket <br />BucketDepth: <br />Wait time between applying <br />vacuum/water and start of test: <br />1 ,�; n ti,? <br />;c <br />Test Start Time (Ti): <br />Initial Reading (Ri): <br />j 3;'y '� <br />%' ?V <br />Test End Time (TF): <br />,+ / z./ J <br />y �j <br />Final Reading (RF): <br />3,� <br />44-/ <br />Test Duration (TF — T): <br />Change in Reading (RF - RI): <br />Pass/Fail Threshold or <br />Criteria: <br />,J ��- !, <br />7 S <br />r <br />a <br />W <br />Comments (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECEMCLA.N RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information. contained "ned in. this report is true, accurate, and infull compliance withlegal requirements. <br />,t <br />Technician's Signature: i^r,: —e,,. Date: i 1 <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 />