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' SWRC'B.January, 2006 <br /> ~hill 13ticket Testing Report Form <br /> This form is intended for use by contractors perJ..rnrrn nuu/testing ul ( l spill The completed lorm cmd <br /> priniouts frons tests (if'applic•ahle), should he provided it)the fac•ilitr owner operator](ir submittal to they local regmlator.v ugenev. <br /> 1. FACILITY INFORMATION <br /> Facilitv Name: SHELL Date of Testing: 5-06-09 <br /> Facility Address: 4315 F. WATERLOO RD <br /> Facility Contact: BILL - --- - Phone: --- <br /> Date Local Agency Was Notified of-resting: 4;29'09 <br /> Name of Local Agency Inspector(il'present during testing): GARRETT BACKUS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: SST-Service Station Testing <br /> Technician Conducting"rest: Heath McEver <br /> Credentials': CSLB Contractor /fC(' service Tech. S%k INCII 1,wk fester Other(SpeciAi-) <br /> License Number(s): 5236750-1 1 --- <br /> 3. SPILL lit ( KIA I LSTIN(: INFORMATION <br /> rest Method Used: thdrostatir - ;i�uun, Other a.. <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket (BY Turk 1 8'7 291 3 - 4 <br /> ,Vnunher. Stored Product. etc.) <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> Contained in Sum Contained in Sump Contained in Sump Contained in Sump <br /> Bucket Diameter: 1 I I I <br /> Bucket Depth: 18.75 It y i <br /> Wait time between applying <br /> vacuum'water and start of test: <br /> rest Start Time(T,): 1 105 1211 <br /> Initial Reading(R,): 17.2i 18 <br /> Test End Time(Tr.): 1205 11,11 <br /> Final Reading(Rr): 17.25 18 — - <br /> Test Duration(TF To: i hr I hr <br /> Change in Reading(Rt.-R,): 0 0 <br /> Pass'Fail Threshold or 0 0 <br /> Criteria: <br /> Test Result: Lr`Pass I I Fail R"Pass Cl Fail ❑ Pass I] Fail Cl Pass U 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 /> !here ht•certify that all the information contained in this report is true,accurate, and in full compliance with legal requirements. <br /> Technician's Signature: Date:-�L��'G'� <br /> ' State laws and regulations do not currently require testing to he performed by a qualified contractor. However, local requirements <br /> may be more stringent. <br />