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SWRCB,January 2006 <br /> SpiR Bucket Testing Report Form <br /> This form is adendedfor me by conwactors performing anmal testing of UST spill contabumeW sirucftwes The completed form and <br /> prWouts from tests(rf applicable),should be provided to the facility owner/operator for submittal to the local regul&WY agency. <br /> 1. FACUffff INV01RMATION <br /> F Nance: Date of T <br /> Facility s: °"-,/5 .0G <br /> Facility Contact Phone: — j <br /> Daft Local Agency Was Notified.of Testing: <br /> Nart�of Local Agency Inspector(rfpresera&uwg testing)= <br /> 2. TESTING CONTRACTOR TION <br /> Company N <br /> Technician gT <br /> C ': 0CSLBContracW JkfCCServiceTech. ❑SWRCB Tank Testu ❑ (Specify) <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used.: ❑Hydrostafic ❑Vacuum <br /> Test Used: <br /> EquipmentResohfim- <br /> Identify (By Tank 1 2 3 �- / 4 <br /> Nzanber,SioredProdtiqeta <br /> B on @F Bury Bury ®Direct Bury <br /> ❑Contained in S ❑Contained in Sump ❑Contained in ❑Contained in S <br /> Bucket Diameftr. , .2 <br /> Bucket Depft <br /> Wait time between applying _ _ <br /> vacuumtwater and of Lest: dG //'l <br /> Test Start Time(171): j <br /> initial Reading 5,� v✓'z ai <br /> Test Fwd Time(TF): <br /> Final Reading ): <br /> Test Duration(TF—Tl <br /> Change in Reading(RF- : --�--�'Pass/Fad Threshold or <br /> Criteria: <br /> Test Result D Pass ❑Fatt Jr Pau ®AM 13 Pass ❑Fal ® Pan ❑Fait <br /> Co ents—(mclude 'mformadon on r prior to testing amd recommended follow-up for failed tests) <br /> CERTMCATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I that all the Wbrma&x centaked in this rVert is legal <br /> Technician's Signature: Date: <br /> d <br /> ' State laws and mgulations do not currently require testing to be performed by a contractor-However,local requirements <br /> mow hp numn.etri'MMMt <br />