Laserfiche WebLink
08/1612007 06:38 FAX BOVETT PETROLEUM @010/011 <br />WRCS, Iftnuam, 2006 <br />Spill Bucket Testing Report Form <br />Tors form is interzdedfol- use by conlraaorsperformtng annual testing of UsTspill contatnnment Slructur•es. TFae cc-rmple:rcd form and <br />printouts from tests (if applicable), should be provlc?ed to the facilily awner,'opet-afor for tubrnittaI to the to, -,21 re ulurory agency, <br />I, 1'e3 UILI"I Y IL b UK:YMLJ IUN <br />i Facility Name; � i3trtc of TCstin�: <br />Facility Address- _25'0/ �ltatc_(*?._..._.t?riC�,...• ...,._..,..ss��a� 43C.Z_.__ <br />Facility Co_ntart: I'ila�riP: V n <br />_ .................... <br />._ <br />bate Local Agency Was Notified of Testing <br />Naptic of I-ocal Agency Inspector lxf prase;nt dtaing tairing,): <br />2. 3 ES DDG CONTRACTOR INFORMATION <br />Co!npart f ;Same L G ��v`c.r . <br />Technician Conducting Test: � __ � ,,..,M . •,,.,,._...,,... _ __ ..w_ .. <br />Credentials. CSI -E Ccn.trartor cr Serjicc TF SIVRCB Tank Tester Other (Specify) <br />License Nuer.(.q <br />3. SPILL BUCKET TFS.CYING IN1F0>; AIATION <br />Test Method Used: HvCltosiatiC.• Vacuum Ctlycr' <br />Teat Euiprnow i,.;sed, „� <br />Equipment Resolution: <br />,3 .4 <br />r identify Spill Rurket (73y 7an)e <br />1 <br />Z <br />Number, Store -d Product, err.) <br />i <br />Blicket Installation TyPC: <br />Direct Bury <br />Coutaixred in Sunn <br />i Direct Bury <br />Contained in Sump <br />Ditto Bury <br />Conmined in Sump <br />Duret 11ury <br />� C optaine(l in 'Sump <br />liuckr•.t T,7i;sa�i�•tcr: <br />�� sr <br />' luckct.Depth <br />TM t`x•• <br />"Wait titzxe betwcct? <br />e vacuum/aater,andl start of tcst: <br />Test Start Tirar, (TI); <br />Initial Reading (R,): ..— . <br />TcSt End Time (TF): <br />w .. <br />I `��►+ I - <br />.... . <br />r Final Reading (k,-): <br />..t <br />l Test DwatiOn M - T& <br />C: "Zze. in Reading (Rr - Rj'): <br />t'ass/katl Tltie,.hrrld or <br />criteria: <br />i <br />r.. <br />TestResult. <br />PASs' ..f=1 i8il.. .0 Pass'' (J t►xI j 0 PASS u Fail, <br />J Pfiss to Fait <br />a <br />C;c>�tluti�YltS — (inelurla. ir,./orTnation ore repairs made rtor to testin?, etnd recommended follow-up for ailed y2 <br />CERTIFICA'110N OF TECHNICIAN RESPONSIBLr rOR CONDUCTWGY THIS TESTING <br />I herehv certify that all the: information contained in rhLs report is true:, accurate, and in full compliance with lcgtal r'egr lrernerus. <br />Tecltnicitcn's Signature: <br />' State laws and do not curxcntl;' require testing to be performed b;: a c uahfizd cunt:ractor.:rlowovcr, local mwiroments <br />may be more vringent. <br />