Laserfiche WebLink
Nov 14 12 12s37p Elite IN Contactors 12094616342 p. 7 <br /> SWRCB,January 2006 <br /> Spin Backet Testing Report 11?4 it <br /> ?'his form is intended for use by contractors performing annual testing of LJST spill c:), .crinment structures.The completed form and <br /> prirnouis from tests(1fapplicable),should be provided to the facility ownerloperator fi •submittal to the local regulatory agency. <br /> 1. FACHM INFORMATION <br /> Facility NauteAl j.� r rite of Testing:_ <br /> Facility Address: <br /> Facility Contact: , Pbene; <br /> Date Lo .Agency Was Notified of Testing: - <br /> Nart of Local Agencyr(df present during testing): Ulfi . <br /> 2.. TESTING CONTRACTOR INFO TIC►1 <br /> Cnvany Name: <br /> Technician.Conducting Test �,Y-Lrod Ur kQrAwtials': 0 CSLB Contractor ICC Service Tech. 0 SWRCB Tank Testa 0 Other(Specify) <br /> License Number(s): _ <br /> 3� SPILL.BUCKET TESTING RMFORMATU I q <br /> Test Method Used: . 0 H drostatic 0 Vacuum C t klier <br /> Test entUse&- Eq iameutResolution: <br /> e� i <br /> Identify Spill Bucket(By Tank 1 2 ( �_ . 4 <br /> AIMM�,Stored ct,etc- <br /> DwIret Installation Type: 0 Direct Bury 0 Dirta Bury C I reef Bury 0 Direct Bury <br /> 0 Coftaified in S 0 Contained in IS .) in Suav 0 in Sump <br /> Bucket Diameter `' U <br /> Bucket Depth- <br /> Wait <br /> epth Wait time between applying _ <br /> vaquumftmter and start of test: <br /> Test Start Time(T1): - <br /> InitW Reading(Rj): <br /> Test End Thne.(TF): <br /> Final Reading(RF): _ <br /> Test Duration(TF—TO: ,- <br /> Change is Reading(RF-R): <br /> PasslFaff Threshold or - <br /> tkiteria: <br /> S Res x' <br /> Cn ents.--(include information ort repairs made prior to testing,and recrrmmend+aa i7lloxx-up for failed tests}. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDU 'nNGTHISTESTING <br /> I hereby certify that all.the information-cn sinned ince repast is true,accurate,ata',i tall compfience withlegal rug ' is., <br /> Technician's,Signature• �~'�'' . ," ✓'� '� Date <br /> $State laws and reguladow-dor not currently requsre testing to be performed by a qualifie:l< 'aftactor.However,localz= <br /> may be m=shing=t <br /> I <br />