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0 <br />SWRCB, January 20( <br />Spill Bucket Testing Report Form <br />This form is intended far use by contractors performing annual testing of UST spill containment structures. The completed form at <br />printouts from tests (if applicable), should be provided to the facility osvner/operator for submittal to the local regulatory agency <br />1. FACILITY INFORMATION <br />Facility Name: ,,q e ,4 L/ A L 6?2b Date of Testing: t e ( a -,"/o7 <br />Facility Address: 23 3� <br />Facility Contact: AL2 Phone: r ,9 _ � 2 <br />Date Local Agency Was Notified of Testing: /0 ,//0/-7 <br />Name of Local Agency Inspector (ifpresent during testing): _4, <br />2. TESTING CONTRACTOR INFOIUMATION <br />Company Name: Champion Precision Testing Inc. <br />Technician Conducting Test: Alvin L. Milburn <br />Credentials': 0 CSLB Contractor [x] FCC Service Tech. 0 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 Levet Change Indicator I Equipment Resolution: .0025" <br />Identify Spill Bucket (By Tank 1 <br />Wait <br />2 <br />3 <br />4 <br />Number, Stored Product, etc.) <br />O <br />Bucket Installation Type: erect Bury <br />i -Direct Bury <br />'Direct Bury <br />❑ Direct Bury <br />Contained in Sump <br />❑ Contained in Sump <br />❑ Contained in Sump <br />❑ Contained in Sum <br />Bucket Diameter: 17 <br />% <br />17Z <br />Bucket Depth: t I <br />i <br />Z <br />(Z - <br />Wait time between applying <br />vacuum/water and start of test: ; .,V <br />s ik . f <br />_y �✓ <br />Test Start Time (T): r — <br />O <br />Initial Reading (Rt): <br />Test End Time (TF): 0-7 5 - <br />Final <br />Final Reading (RF): <br />Test Duration (TF - TO: 2 <br />i i 1/4, <br />Change in Reading (RF -Ri): <br />Pass/Fail Threshold or <br />Criteria: <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 TESTVNG <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requiremenj <br />Technician's Signature: ��C'��- —� Date: V <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />rnov Fla Mr%ra ctrin", nt <br />