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Sep 17 09 02:10p Elite IV Contactors 120946 6342 p.4 <br />SWRCB, January_2006 <br />Spill. Bucket Testing Report Form <br />This fornnc is intended for use by contractors peiforrnirag annual testing_af .UST'spill containment structures- The completed}orm and <br />priritouir from tests (if applicable), should`bepr6 ded ta•thefacWty owner/operator for submittal to the local'regulatary agency <br />TNFORIWIATION. <br />Facility Name:: "'''r <br />Date of Testing: <br />Facility Address: 3 i <br />Facility. Contact: Phone: <br />Date Local Agency as Notified of Testing.: ' <br />Name. of Local.Agency Inspector rf present during testing}:. <br />2. TESTING CONTRACTORI FORMATION <br />Con�ianyName: j.- v✓ <br />T=bnician Conducting Test: i• r a ` <br />Credeatials': ❑ CSLB Contractor J�ICC <br />Service .Tech D SWRCB Tank Tester • ❑ Other (�Pfy) <br />License Number(s): i;!• Wl..f <br />3. SPILL BUCKET.'TESTING INF® TION <br />Test Method -Used: 0 Hydrostatic ❑ Vacuum ❑ Other <br />Fest Equipment <br />Used.Equipment Resolution: <br />Identify Spill Bucket (By Tank 1 2 3 4 <br />Number, Stored Product, <br />P'Direct Bury 'Direct Bury irect Bury ❑Direct Bury <br />Bucket Installation Type:. ❑Contained in S ❑ Contained <br />in 0 Contained in S ❑ Contained in S <br />Bucket Diameter <br />Bucket Depth: t"Z;' ` l Z- Z <br />Wait time between applying <br />vacuum/water and start of test: <br />'fest Stant Time (Ti): `z - 2� Z <br />Initial Reading (Rt): t -Z, Z <br />Test:Ei►d Time (TF):. <br />Final Reading (RF): ' t 7, '/ Z". <br />Test Duration (TF - TO: <br />Change in Reading (RF = Rn): . <br />PasslFail Threshold or <br />Crrterra: r <br />C®it3lnentS include inforntation on repairs made prior to iestutg, and recotnntended foXlmv-up for foiled tests): <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CUNDUCZTNG TENS TESTING. <br />I hereby certify tliat aril the information: contained in: this report is. true, accurate. and. in. frail carepliance with. legal requirements.. <br />Technician s Signature• : ! ��� y� s Date <br />$ s and regulations do not currently require testing to be performed by a gtnalified contractor <br />StatG law . However, local requirements <br />Mbe mare sig agent: <br />