Laserfiche WebLink
0 �_ SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intendedfor use by contractors performing annual testing of UST spill containment structures. The completed form and <br />printouts front tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />I_ FAC_ILITV INFORMATION <br />Facility Name: -t j-- Date of Testing: , <br />Facility Address: <br />Facility Contact: t±, �t ,e { Phone: <br />Date Local Agency Was Notified of Testing: ' <br />Name of Local Agency Inspector (if presentring testing): <br />PIM <br />IKLM L4314WIM, <br />Company Name: i <br />Technician Conducting Test: <br />Credentials': CSLB ContractorService TerO SWRCB Tank Tester Other (Specify) <br />License Number(s): <br />&+ BU SET TESTING INFORMATION <br />Test Method Used: maydros Vacuum Other <br />Test Equipment Used: <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank�I' <br />Ntbtber, Stored Product, etc. <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />Direct Bury <br />Contained in Sump <br />Direct Bury <br />Contained in Sum <br />Direct Bury <br />Contained in S <br />t Bury <br />retained in Sum <br />Bucket Diameter: <br />�y <br />Bucket Depth: <br />/ <br />LL <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Tj): <br />Initial Reading (Rj): <br />^- r <br />Test End Time (TF): <br />Final Reading (RF): <br />.� <br />Test Duration (TF — Tj): <br />�^ <br />in Reading (RF - R): <br />Pass ail Threshold or <br />tteria: <br />Test Result: <br />Pass Fait <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />•,uwuicuw — (inctuae znjormatzNL2ajrpairs made prior to testing and recommended follow-up far failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the inf rmation contained in this report is true, accurate, and in full compliance with legal requirements <br />a—.�.5D-0 ?( -) <br />Technician's Signature: Date: <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 />BMs <br />