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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 spall containment structures. The completed form 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: tAj2eC Date of Testing: <br /> Facility Address: d t &A <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): M14 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: HMC-Henderson Maint Co <br /> Technician Conducting Test: Gavin Williams <br /> Credentials': ❑CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): t ( 7/1 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1. T-1 Reg 2. T-2 Sup 3 ,D;Stj 4 <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: `uect Direct Bury irect Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: °( '/ cs <br /> Bucket Depth: .. /® 6®/ 1XII <br /> Wait time between applying <br /> vacuum/water and start of test: k✓® / t/ (� <br /> Test Start Time(TI): = <br /> Initial Reading(RI): <br /> Test End Time(TF): <br /> Final Reading(RF): 10 ®/ 'If <br /> Test Duration(TF-TI): Y- k vlar <br /> - <br /> Change in Reading(RF-RI): 6A16 e- <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: Pass ❑Fail Nefass ❑Fail Pass ❑Fail ❑ Vqss ❑Fail <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> r <br /> Technician's Signature: _ Date:_ <br /> 'State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> 4Y1.] l 11A Y1ll�YP CIYl1lRPOl* <br />