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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 spill 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 /> Facility Name: <br /> I. FACILITY INFORMATION <br /> e� - ? <br /> Facility Address: -L6 [A Ci V ate of Testing; <br /> y, 1i c D�„ <br /> Facility Contact: �, <br /> Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector (if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: 7— <br /> Technician Conducting Test: �' r, <br /> Credentials': ❑CSLB Contractor CC Service Tech. Q SWRCB Tank Tester Q Other(Specify) <br /> License Number(s): <br /> 3. -VJLL BUCKET TESTING INFORMATION <br /> PTest <br /> Method Used: 4Tanki <br /> ydrostatic Q Vacuum <br /> Equipment Used; Q Other <br /> Equipment Resolution: <br /> ify Spill Bucket(By 2 3 <br /> Number, Stored Product, etc. C 4 <br /> Bucket Installation Type: irect Bt�t} irect Bury O Direct Bun ❑ <br /> pirect Btuz� <br /> 0 Contained in Sum Q Contained in Stun ❑Contained in Sum Q Contauied in Suri <br /> Bucket Diameter: .2 ft <br /> Bucket Depth: <br /> Wait time henveen appl ing <br /> �acuumAvater and start of test: ! 19 ir'tf '^ ! d #Ift IA- <br /> Test <br /> Test Start Time(Tj): 9C1b /O c3 d <br /> Initial Reading(Ri): /' rl �� r <br /> Test End Time(TF): 10040 r l a p <br /> Final Reading(RF): oil l U <br /> Test Duration(TF-TI): I A f <br /> 2, Pass <br /> Change in Reading(RF-RI): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: Pxss 0FailD Fail ❑ Pass Q Fail Q Pays f1 Fxi! <br /> Comments—(include information on re airs made prior to testing, and recommended f)llow-u or 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 /> Technician's Signature: Date: Z cj —Z O—C1 <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> mav hA mnm ctrino l <br />