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SWRCB, January 2006 <br />Spill Bucket "Testing Report Form <br />This form is intendedfor use by contractors performing annual testing of UST spill containment structures. The completed form and <br />printouts f -oin tests (i applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br />1, FACILITY INFORMATION <br />Facility Name: �;A° Date u(Testing. - <br />~Facility Address: 35 <br />Facility Contact Phone: X70 <br />Date Local Agency Was Note jed of Testing: <br />Name of Locai tlgency Inspector (rjpreserrt during testingj: <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY <br />Technician Conducting Test: <br />Credentialsl: ICC 'Service Tech. D SWRCB Tank Tester fv, Other (Specify) <br />CSLB Contractor -. <br />License Number(s): 04 11 <br />3. SPILL <br />BUCKET TESTING INFORMATION <br />Test Method Used. Hydrostatic C Vacuum 3 : Other <br />Test Equipment Used: ,p Equipment Resolution, <br />... k. <br />identify Spill Bucket (!gip Tank <br />1 <br />23 <br />4 <br />Number, Stored Product, etc.) <br />Bucket Installation Type: <br />` Direct Bury <br />0 Contained in S'u�m <br />Obirect Flury <br />�":1 Contained in Sum - - <br />Direct Bury <br />F Contained in Syp <br />L: Direct Bury <br />1"]Contained in Sum <br />Bucket Diameter: <br />�- <br />?" <br />Buckct Depth: <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Tj): <br />s ( <br />"o <br />;.0 <br />Initial Reading (Rj); <br />`fest End Time (TF): mm <br />' l97 <br />175,10/ <br />Final Reading (RF): <br />{ <br />Test Duration (Tr - Tj): <br />-OA" ' <br />v r— <br />A0,VA- <br />Change in Reading (Rt: - Rj). <br />PasslFaiI Threshold or <br />� <br />C.)S � <br />� 5�5 <br />Criteria: <br />Test Result, <br />A51pass D Fait <br />5ePass 0 Fall <br />Pass 0 Fail <br />0 Pass G Fail <br />Comments- (include it1for motion on repairs made prior to testing gird recorntnendedfollow-t p (or failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby eertt(j7 that all the In ormation contained i)t this report Is true, accurate, and In full compliance with legal requirements, <br />Technician's Signature: Date: ci <br />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 />