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Oct 25 07 10: 03a Elit- Iv Contractors Inc 2094G1Gg42 p. l <br /> tlti . <br /> V/ . OV- 0/3r <br /> 14 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 ownerloperator for submittal to the local regu'IAtgty agency , _ <br /> 1. FACILITY INFORMATION <br /> Facility Name: Date of Testing: <br /> Facility Address: n ��U 7 <br /> Facility Contact: Phone: a(� •q - .' '' HEALTH <br /> Date Local Agency Was Notified of Testing: Pf7Q M '/IrFC <br /> Narne of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR . FORMATION <br /> Company Name: <br /> Technician Conducting Test: <br /> Credentialst: 0 CSLB Contractor M ICC Service Tech 0 SWRCB Tank Tester 0 Other(Specify) <br /> License Number(s):- dQ7 <br /> 3_ SPILL BUCKET TESTING.INFORMATION <br /> Test Method Used: Hydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used: - Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 �--; f 2 3 4 <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: irect Bury 0 Direct Bury 0 Direct Bury 0 Direct Bury <br /> ❑Con w S 0 Contained in Sump 0 Contained in Sump 0 Contained in SUMP <br /> Bucket Diameter: <br /> Bucket Depth <br /> Wait tune between applying . e, <br /> vacuum/water and start of test: <br /> Tcst Start Time(T,): '�;�'�C� <br /> Initial Reading(Rj): <br /> Test End Time(T,): <br /> Final Reading(RF): <br /> Test Duration(TF-TI): <br /> Change in Reading(RF-Rt): p,; r•i^ �r <br /> pass/Fail Threshold or a, <br /> Criteria <br /> LTs_a_ss,rd3 � �4 s� <br /> WI <br /> Comments—(include infognation on repairs made prior to testing,and rec mended follow-up forfailed tests) _ <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certifythat all the information contained-in.this report is tr ,accurate,and in fug compliance with legal requirements. <br /> Technician's Date: '� <br /> T $ <br /> t 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 />