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Rug•24 12 11:04a Elite IV Contactors 12094616342 <br />p.8 <br />SWRCB, January 2006 <br />Spin Bucket Testing Report i? 4 irm <br />Tiads form is intendedfor use by contractors performing annual tenting of LIST spall c2i irinment structures. The completed• form and <br />printouts from tests (f applicable), should be provided to the facility ownerloperator fc submittal to the local regulatory agency: <br />1. FACIOMY MFORMATION <br />Facility Nana <br />Facility Address: <br />J <br />Facility Contact -I Phone: <br />Date Local Agency Was Notified of Testing: —_ <br />Naax of Local Agency Inspector �fpresentduring testing): C, {sl j j IF'.� <br />��r� ��11� 1►Ct�i7i7ar�[r�IT7i�� r13at��� = t� <br />Company Narne: � i' <br />r '�i�.�'��'C � <br />_ . <br />.fes <br />Technician Conducting Test <br />c ed Lr Ac— <br />Credeatialsi: 0 CSI,$ Contractor ICC Service Tech 0 SWRCB Tank Test:x 0 Other (Specify) <br />— <br />License Number(s): <br />SPILL. $UCKET. TESTING MFORMAT Ed 1+7 <br />Test Method Use&- <br />0 $ drosiatic 0 Vacuum <br />C i tier <br />Test Eq ' Used: <br />I q ipment Resolution: <br />Identify Spit Bucket (By Tank <br />1 2 (-� p <br />3' 4 <br />AWnber, Stored Product, etc-) <br />et Installation Type: <br />0 Direct Bury 0 Buy <br />C I root Bury 0 Direct Bucy <br />0 COntaided in S 0 Cori in uS' <br />C C :intained in S 0 Contained m SUMP <br />p����y <br />Bwket Diameter: <br />Bsucket Depth: <br />teG' YA A / 1 r. I- <br />'Y <br />Wait time applying <br />vacuumfwater and start of test: <br />Time (Ti): <br />�T�esst_pStart <br />Initial Reading (R,): <br />— <br />Test End Time .(TF): <br />_ <br />Final Reading (RF): <br />- <br />Test Dmattion M -TO: <br />ChaW in Reading (RF - Rr):015- <br />Pass/Fail Threshold or <br />— <br />Comments = Cmdude iriforrnatia'n-on repairs made prior to testing and recommend+!a ;illm up for fatTed tests). <br />CER CATION OF TECHNICIAN RESPONSIBLE FOR CONDt3( TING THIS TESTING <br />I hereby cm1#5P that all Mein}ornratioaa. cotr:�aerrined�i&d� report is. true; accurate, ani.! i ' full compliance with legal requirements.. <br />Technician's. Signatu =- Ij 1 l Date: �5/ <br />u State laws and regularcow do not currently require testiag to be perfomed by a qualified i )atractaou: However, local requircnxwts <br />may be more stringent. <br />