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E <br />Spill Bucket Testing Report Form <br />This form is Jnten*dfor use by contractors performing annual testing of UST spill containment structures <br />The completed form and printouts from tests (if applicable), should be provided to the facility <br />owner/operatorfor submittal to the local regulatory agency. <br />Facility Name 1. FAC11,17FY INFOTION <br />RMA <br />L�� -T-TA ` /) Date of Testing: <br />- ----F <br />Facility Address: <br />Facility Contact: J)q b 6 C S. <br />Phone: <br />Date Local Agency Was Notified of"Testing : 01 -zdQ 1 1 <br />Name of Local Aizencv Insnector (if tovii"-1. <br />Test Method Used: <br />k-ITy-drostatic <br />El Vacuum <br />Test Equipment Used: <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 <br />2 <br />3 <br />aa- C <br />Bucket Installation Type: <br />IR7 Nrect Bury <br />Contained in Sump <br />erect Bury <br />0 Contained in Sump <br />erect Bu <br />ry0 <br />0 Contained in Sump <br />k�t Bury <br />0 Contained in S <br />Bucket Diameter: <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test: <br />13 <br />t 3 <br />Test Start Time (Ti): <br />01 <br />VIC, <br />Initial Reading (Ri): <br />tl <br />Test End Time (TF): <br />L Avv,, <br />11, At:a <br />I a4� <br />Final Reading (RF): <br />Test Duration (TF - Ti): <br />Change in Reading (RF - 14): <br />Pass/Fail Threshold or Criteria: <br />Test Result <br />) <br />&"P-ass0 Fail <br />0 Fail <br />Pass 0 Fail <br />0 F <br />Comments — finrludP lnfnr nirtinss ry irc M -As <br />failed tests) <br />CER CATION OF TECHNICUN RESPONSIBLE FOR CONDUCTTNG THIS TESTING <br />I hereby cerci; tkat all the information contained in this report is true, accurate, and in fall compliance <br />with I al requirements <br />Technician's Signature:_ Date: <br />