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NECEIVE:1) <br />4 'J' ' 10 2017SWRCB, January 2006 <br />Spill Bucket Testing Report F&MRONMENi�L HEALTH <br />This form is intended for use by contractors performing annual testing of UST spill containmeRni'1sTi'i���E9;he 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: LAWRENCE LIVERMORE LABORATORY Date of Testing: 06/29/2017 <br />Facility Address: 15999 West Corral Hollow Road, Building 879 <br />Facility Contact: DIANE GRIFFIN I Phone: 925-423-1547 <br />Date Local Agency Was Notified of Testing: 06/22/217 <br />Name of Local Agency Inspector (f present during testing): Elena Manzo <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: CENTRAL PETROLEUM <br />Technician Conducting Test: GREGG GELTZ <br />Credentials': X CSLB Contractor X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s):491948 5250561 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: X Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: WATER —TAPE MEASURE <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />87 Fill <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />X Direct Bury <br />❑ Contained in Sump <br />Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />14" <br />Bucket Depth: <br />14" <br />Wait time between applying <br />vacuum/water and start of test: <br />2 MINS <br />Test Start Time (Ti): <br />13:36 <br />Initial Reading (Ri): <br />11 5/8" <br />Test End Time (TF): <br />14:36 <br />Final Reading (RF): <br />It 5/8" <br />Test Duration (TF — T,): <br />I HR <br />Change in Reading (RF - Ri): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16" PER HR <br />Test Result: <br />X Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />New swill bucket gassed testing - <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: _ y1 <br />' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />��C Z-, IIrl V FA Do o _? ('-(. "- <br />