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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 sufmittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: r,'ar Date of Testing: 9- /!?-Q <br /> Facility Address: 1'3l�Cca, i G Av-e, CQ • 95go ? <br /> Facility Contact: r-ay1Phone: le dL <br /> Date Local Agency Was Notified of Testing: g-a-a--o '7 <br /> Name of Local Agency Inspector(if present during testing): P <br /> y on u <br /> 2. TESTING.CONTRACTOR INFORMATION <br /> Company Name: -t -D Co vK 9G. ;,r` <br /> Technician Conducting Test: a vt` o wry Z v1 Itir, 'C.h , <br /> Credentials': CSLB Contractor ICC Service Te SWRCB Tank Tester Other(Specify) <br /> License Number(s): `10 - l l 90 <br /> 3. UCKET TFSTING.INFQRMATION. . <br /> Test Method Used: Hydrostatic Vacuum Other <br /> Test Equipment Used: r� S��r� . Equip ment,Resolution: <br /> Identify Spill Bucket(By Tank TCL^ 1 2' aY` a 3 t'arl� 3 <br /> Number, Stored Product, etc.) ulcer rF' ` ne w��(tirti ( ` te5 ( F l <br /> Bucket Installation Type: Direct Bur irect Bury Direct ury irect Bury <br /> Contained in Sump Contained in Sum ontalne_ —In Sum p tained in S m <br /> Bucket Diameter: <br /> Bucket Depth: /4 <br /> Wait tim een applying <br /> vacuo water nd start of test: 10 n";P1&few In m ria<jC5 rv-i n ilr� <br /> Test Start une(TI): /0- 30 D : -30 ® ' 30 <br /> Initial Reading(RI): 1/ " q tl <br /> .Test End Time(TF): ; 3 p 3 <br /> Final Reading(RF): 16- <br /> .Test Duration(TF-TI): <br /> Chan e in Reading R <br /> g g( F'R I)� � ' <br /> Pass/Fail Threshold or <br /> Cilteria: t I r �tc�vv I(<� L VLOu✓: �1�/f t v�. :� .r <br /> e y <br /> _Co"-mments-(include information on repairs made prior to testing,.and recommended follow-up for failed tests) <br /> V1 5t,«t OX44- -I s-1 Par l"'e..• i r, d i rw E 5pi it V)L4C�-C'+ 5h01x-\-S Gi s a�cc t t <br /> CERTIFICATION OF TECI4NICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained ii is eport is true,accurate, and in full compliance with legal requirements. <br /> h �Technician's Signature: Date: <br /> ' State laws and regulations do not currently require testing to Xperformed by a qualified contractor.However, local requirements <br /> may be more stringent.- <br />