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SWRCB,January 2006 <br /> Spit Bucket Testing Report Farm <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests Cf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: C Date of Testing: <br /> Facility Address: o b 5�a ,a�2c,ate- E+' e <br /> Facility Contact: /c <br /> Date Local Agency Was Notified of Testing: l /g t o <br /> Name of Local Agency Inspector(if present during testing): to �,� ,o�L q t��c <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Champion Precision Testing Inc. <br /> Technician Conducting Test: Alvin L.Milburn <br /> Credentials': ❑CSLB Contractor [x]ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 0878949-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [xj Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Caldwell Level Change Indicator Equipment Resolution: .0025" <br /> Identify Spill Bucket(By Tank I 2 17 3 4 <br /> Number, Stored Product, etc.) q t <br /> Bucket Installation Type: ff TSrect Bury 91hrect Bim' ❑Direct Bury 0 Direct Bury <br /> C Contained in Sump C Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: r-51'�- v /";� ,s 4 <br /> Bucket / `' l <br /> Wait time between applying <br /> vacuum/water and start of test: ��c vr►J <br /> Test Start Time(171): /0 o <br /> Initial Reading(RI): of <br /> Test End Time(TF): ��3 <br /> Final Reading(RF): <br /> Test Duration(TF-Tj): k�- <br /> Change in Reading(RF-Rj): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> € F s>> <br /> .:..:............... <br /> Comments-(include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> %pec c&,E� <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 /> Technician's Signature: Yo 6-T <br /> ` Date: <br /> r State laws and regulations do not currently require testing to be performed by a qualified contractor.However, local requirements <br /> maw I%A mr%v+ctrinoPnt <br />