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04-23-'12 10,56 FROM-west Star Envmt Inc. +559-277-0106 T-769 P0006/0006 F-311 <br /> 0 0• S'VVRCB,Januay 2006 <br /> Spill Bucket 'Testing Report Form <br /> This form is intended for vsv by contractors performing annual testing of UST spall containment structures. The completed fonn and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency <br /> 1. FACILITY INFORMATION <br /> Facility Name: cj %Date of Testing: -7 Z <br /> Facility Address: v <br /> Facility Contact: Phone: :Wet- 159- <br /> bite Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TRSTING CONTRACTOR INFORMATION <br /> Com any Name: W e,$� S 1C" EX% ro <br /> ti Technician Conducting Test: ackyna 4PIALK6.1; <br /> Credentials,. ❑CSLB Contractor Ricc Service Tech. 0 SINRCB Tank Tester ❑Other(Spec ) <br /> License Number(s): <br /> 6 <br /> b 3. SPILL BUCKET TESTING INFORMATION <br /> { Test Method Used: H drastatic 0 Vacuum 0 Other <br /> Test Equipment Used: Equipment Resolution: <br /> 2MMEMEEN= 1. <br /> Identify Spill Bucket(.6y Tank 1 B-7 2 11 3 'fit A <br /> Number,.Stored Product,etc. V I <br /> >, JR Direct Bury Voirect Bury .9 Direct Bury 0 Direct Bury <br /> ' _. <br /> Bucket Installation Type: 0 wined in Sum �1 Contained in Sum ❑Contained in Sum CJ Contained in Sum <br /> Bucket DiameterZi' 12°' 2t r <br /> Bucket Depth: t t r L r t <br /> Wait time between applying mrn <br /> vacuum/wat&and start of test: <br /> Test Start Time(TD: n <br /> Initial Reading(Ftr}: e! �� e< <" V <br /> Test End Time(TF): <br /> Final Reading(RF): <br /> Test Duration(TF Tr): JC hair h �� <br /> Change in Reading(RF-RI): <br /> Pass/Fafl Threshold of <br /> 4 .; qhq, ,,. • . •••, �,. _)rJ . . S.e. r. �''w`'{ ;'!" �Jti ii" �',$ y ' fit d. <br /> . p�F�n.''..JyT% .•..4•l.•• , 3 . �.. ' Yl u ). :' .CS7.�3r` f i !4 d:n ..f•WJN�P.'./ <br /> ;�, •:. z%�.Sa .�'4;i.:a...;.:4+YvA:+k'.�.�2;"i• � k x� : •v}`"^t' ... ?%%� ..r..,,1�:'• •"�" <br /> Comments—(include information on repairs made prior to testing,and recommended•rollaw-re or,failed tests) <br /> i <br /> CE1tTYFICATIOIV OF TECHNICIAN RE5PONSIBI.E FOR CONDUCTING TRIS TESTING <br /> X hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements; <br /> Technician's Signature: `r' V Date: <br /> 'State laws and regulations do not curcentiy require testing to be performed by a qualified contractor.however,locat requirements <br /> may he more stringent. <br /> j <br /> . i <br />