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SWRCB, January 2002 rage o� <br />acYay [T6i RW'iT.i. f`tll\TTATRTIVT�i',10TT ROXIE'+.& <br />Commenis — (include informati. n on repairs made prior to testing, and recommended follow-up for failed tests) <br />Please direct any comments regarding this form to: <br />SWRCB UST Program, Attn: Scott Bacon <br />1001 "1" Street, Box 944212 <br />Sacramento, CA 95814 <br />Phone: (916) 341-5873, Fax: (916) 341-5808 <br />e-mail: bacons@cwp.swrcb.ca.gov <br />k <br />Facility is Not Equipped With Spill/Overfill Containment Boxes ❑ <br />Containment Boxes <br />are Present, but were Not Tested ❑ <br />Spill/Overfill <br />Test Method Developed By: <br />❑ Spill Bucket Manufacturer dustry Standard ❑ Professional Engineer <br />❑ Other (Spec) <br />Test Method Used: <br />❑ Pressure ❑ Vacuum Hydrostatic <br />❑ Other (Specie) <br />Equipment Resolution `' <br />Test Equipment Used: `� i t u -p w a -rte tb <br />.. , =:�is;° <br />MEM1 <br />l `P-- <br />S 111 BOX # Spell BOX # Spell BOX i$. <br />Q? SpiIIBOX# j a)! p <br />,fi«r :w ,a <br />Bucket Diameter: <br />b t l I <br />Bucket Depth: <br />4 3 <br />Wait time between applying <br />pressure/vacuum/water and <br />starting test: <br />Test Start Time: <br />g o l <br />Initial Reading (Ri): <br />Test End Time: <br />l Y o <br />Final Reading (RF): <br />Test Duration: <br />'<, N.., <br />Change in Reading (RF-Ri): <br />Z 'r <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />I Pass ❑ Fait ❑Pass Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Commenis — (include informati. n on repairs made prior to testing, and recommended follow-up for failed tests) <br />Please direct any comments regarding this form to: <br />SWRCB UST Program, Attn: Scott Bacon <br />1001 "1" Street, Box 944212 <br />Sacramento, CA 95814 <br />Phone: (916) 341-5873, Fax: (916) 341-5808 <br />e-mail: bacons@cwp.swrcb.ca.gov <br />k <br />