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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(if applicable:),should be provided to the facility owner/operator,for submittal to the local regulatory agency. <br /> 1. FACILITY INFORR'IATION <br /> Facility Names: '� l Date of Testing: 0-/2-- 2, [&I <br /> Facility Address: <br /> Facility Contact: Phone: <br /> REdiaL <br /> 2. TESTING CONTRACTOR INFORMATION OCI 15 .201 <br /> Company Name: ELITE IV CONTRACTORS <br /> Technician Conducting Test: ENVIRONMENTAL HEALTH <br /> Credentials: CSLB Contractor=X ICC Service Tech. SWRCB Tank Tester Other( Mil <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostati Vacuum Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) 'J6� I <br /> Bucket Installation Type: X Direct Bury X Direct Bury X Direct Bury Direct Bury <br /> Contained in Sump Contained in Sump Contained in Sump Contained in Sum <br /> Bucket Diameter: <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: 0 Mtiv, j(.) /tet%✓ <br /> Test Start Time(Tj): <br /> Initial Reading(R,): l I <br /> Test End Time(TF): <br /> Final Reading(RF): � <br /> Test Duration(TF-Ti): -�r2 <br /> Change in Reading(RF-Ri): <br /> Pass/Fail Threshold or r S <br /> Criteria: ( L / <br /> Test Result: Pass 'Fair Pass ❑Fail Pass D Fail ❑ Pass ❑Fail <br /> COmrnen IS- (include information on repairs made prior to ng, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: ,-, M _ _ Date: 6-12-209' <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />