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11 <br />0 <br />SWRCB, January 2006 <br />'his form is intended for use by contractors performing annual tesung of UsT spill contain rcent 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 />i=ZL ill F II VA 101 !` C ►>t_ i N <br />Facility Name: H&M — ---- - - Date of T ! <br />Facility Address:2501 <br />Facility Contact: MIKE; lshone:2 <br />Date Local Agency Was Notified of Testing: A U G <br />Name of Local Agency Inspector Wpresent during testing): <br />2. -R_ fig, . kWks : ltl' i ii►>E V _. <br />Company Name: LC <br />Technician Conducting "fest: <br />Credentials: ❑ CSLB Contractor X ICC Service Tech, L SWRCB Tank Tester ❑ Other (S ecify) <br />License Number(s)-81437$3 <br />CIERTIFI+CATION OF TECHNICL4.N RESPONSIBLE FOR CONDUCTING THIS TESTING <br />.I hereby certify' that all the.informadon contained in this teporl is trite, accurate, and In full compliance with legal requkemenm <br />Technician's Signature: Date: <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 />3, SPILL BUCKET 'VESTING ENFORMATION <br />Test Method Used: <br />X Hydrostatic <br />❑ Vacuum <br />Q Other <br />Test Equipment Used: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product etc.) <br />1 87 <br />2 91 <br />Equipment Resolution: <br />3 DSI. 4 <br />Bucket Installation Type: <br />X Direct Bury <br />❑ Contained in Sum; <br />X Direct Bury <br />0 Contained in Sump <br />X Direct Bury Q Direct Bury <br />0 Contained in Sum ❑ Contained in Sump <br />Bucket Diameter, <br />121, <br />12" <br />12" <br />Bucket Depth: <br />14" <br />14" <br />19" <br />Wait time between applying <br />vacuum/water amend start of test: <br />30 MiN. <br />30 MIN. <br />30 MIN. <br />Test Start Time (Ten}: <br />9:22 AM <br />9:22 AM <br />9:22 AM <br />Initial Reading (iii: <br />13.50" <br />12.75» <br />1 s„ <br />Test Emend Time (TF): <br />10:22 AM <br />10:22 AM <br />10:22 AM <br />Final Reading (RF): <br />13.50" <br />'12.75" <br />1s" <br />Test Duration (TF — Tr): <br />I HOUR <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - Ri): <br />0 <br />0 <br />0 <br />Pass1W Threshold or <br />Criteria: <br />002 <br />.002 <br />x002 <br />r..reMI,.114'•ir':"I:e YW9rrp.ra'I:rY"1•n'ri .r.;i:: i8.le'ml ".:.r'; ... •ii,:tll.9iwrr.rrWrx.yr.. vr.r...«nri.wr.r.r.rr..uer...r ..r....... wr e..rr. <br />• ...yr 4.„.. •r r,e-�Il..lrlr�riol� arskrnn.lr. r.r �. .....a. ..._ r..l. •.I •q .•. r., w. ,.: >,•�:. �v..r... <br />1... ,e II'+.a°Id..i.yr. ;4; rpl;w :MI1.br n I •. ••. 41: •fG:4e c:' K:•n; 11M ••';H •e.m.anWt.' q"r 14 .iYiM1.i:.4�..IC�ci:^'�: ii.9^i:iie: A'i'ti 1��1':uyyi' �tv :9;Be7'r.: ^!q••'lii •..gllr�'ri <br />ill ':r:. .gRuwl„:mN •a'£:,yyn kri !n 1jp�j �•r.�t�••Y 61n�pl.Iei!?, ' aw•l .r'<:aT 6 t •.• ernral <br />1•"1::416i5r,VfrN 1 h ortwi r,•u1:iM� 'v`'1:�. "a::rM.R ^`.i,?1��:1 i.•� OI�.N'l <br />�..., m I}� • •s�f?iln•1"w. I.seFR'r �t ��.1R1{Zr:hT�np p .Y.+14xra�:i*f9��111di��,rrr �r; d4�'. 4 . rvr.n <br />r.. r .. rirr .. .x i r roar .m .. .. « .. urr n r i rv... •.... • v. Ik, <br />COMMentS — (include i ormation on repairs made prior to testing, and reconmmended follow-up for failed tests) <br />CIERTIFI+CATION OF TECHNICL4.N RESPONSIBLE FOR CONDUCTING THIS TESTING <br />.I hereby certify' that all the.informadon contained in this teporl is trite, accurate, and In full compliance with legal requkemenm <br />Technician's Signature: Date: <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 />