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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 ownerioperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: y$ r Date of Testing: <br /> Facility Address: <br /> Facility Contact: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): 4 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Champion Precision Testing Inc. <br /> Technician Conducting Test: ...S <br /> Y. <br /> Credentials': 0 CSLB Contractor [xj ICC Service Tech. 0 SWRCB Tank Tester 0 Other(t'1?pectCv) <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [xj Hydrostatic ❑Vacuum 0 Other <br /> Test Equipment Used: Caldwell Level Change Indicator Equipment Resolution: .0025" <br /> Identify Spill Bucket(By Tank 1 23 4 <br /> Number,Stored Product, etc.) ` t <br /> Bucket Installation Type: irect Bury Direct Burt- "*Direct Biu}- ❑Direct Bun- <br /> um Contained in Sum 0 Contained ill Sump 0 Contained in Stunp 0 Contained in,Stuu <br /> Bucket Diameter r i <br /> Bucket Depth: <br /> Wait tine between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T): 61�0 <br /> Initial Reading(RD: r i a13 <br /> Test-End Time(FF): 16 6 J i ,(j 166 <br /> Tinal Reading(RF): r t 3 ` 3 l <br /> Test Duration(TF-TI): f / <br /> Change in Reading(RF-Rt): <br /> PassTail Tlu-eshold or <br /> Criteria: <br /> Test Result: Pass ❑Fail. Pass 0 Pail ass ❑Fail ❑ Pass 0 Fail <br /> Comments- (include information on repairs made prior to testing and recontrntended follotit-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that an the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: <br /> �..FiC- Date: - a G <br /> t Statelaws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> M",tw mnro rtr;naPnt <br />