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From: Franzen -Hill Inc. To: 12094683433 Page: 7/8 Date: 1! /201211:45:09 AM <br />Spin Bucket Testing Report For <br />SWRCB, January 2006 <br />This fonn is intended for use by contractors performing annual testing of UST spill containment structures. The completed fora: and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agenc1� <br />1. FACILITY INFORMATION <br />FacilityName: � i �,', ,nti uvv 77=Date of Testing: I 13 12 <br />Facility Address: tt:- w'Aok-� <br />Facility Contact: Phone: Ze 1- _ 119'(4 to <br />Date Local Agency Was Notified of Testing: 1 ( Z W <br />Name of Local Agency Inspector (ifpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: X Hydrostatic El Vacuum Q Other <br />_ <br />Test Equipment Used: Equipment Resolution: .0 1 <br />Identify Spill Bucket. (By Tank <br />Arurnber, Stored Product; etc.) <br />1 <br />to 1 <br />2 3 <br />C(, <br />4 <br />Bucket Installation Type: <br />VI Direct Bury <br />D Contained in S!pp <br />6 Direct Bury 0 Dir t Bury <br />© Contained in Swpp 0 Con�wmcd in Sump <br />0 Dire Bury <br />©Contain d in Sum <br />Bucket Diameter: <br />Bucket Depth: <br />i r, <br />171 <br />Wait time between applying <br />vacuunilwater and start of test: <br />Test Start Time (Tz : <br />/ty 00 <br />jty� <br />Initial Reading (Rx): <br />1511 <br />1$' <br />Test End Time (Tr): <br />Final Reading (RF): <br />Test Duration (Tr -- T�: <br />Change in Reading (Rr-RI): <br />100 <br />vwk <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />]Pass 0 Fail <br />Pass: a:3Fai1 Q I:a CJ Fain . <br />fl lass €7 Fail <br />Comments --- (include information on repairs made prior to testinK,, and )ecommended follow -zip for failed tests) <br />CERTIFICATION OF <br />I herehy certify that ill the informati <br />Technician's Signature: _ Jesse <br />4N RESP ?' NSIBLE FOR CONDUCTING THIS TESTING <br />in this r ort is true, accurate, and in full compliance with legal requirements. <br />Date: t / 3l( Z <br />' State laws and regulations do not c u/emly require testing to be performed by a qualified contractor. However, local requirements <br />This fax was sent with GFI FAXmaker fax server. For more information, visit: http://www.gfi.com <br />