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• <br />3 2,913 <br />E,N; V R 0 N? M F: <br />Spill ti'act, 3, Report Forn, orm '7' <br />'�et Testing onrainmem,�1"Mre,s' The coroplete4f <br />0,01 ..ulalory agl"'Y, <br />terming <br />annual """ng of USr SP' r submittal 10 the <br />This •form is intended for use by contractors Pe"ff ded to thefaCIMY ow ' nerIoPeralo"fo <br />'2pplic,ble). should be prOvi of Testing; <br />Printouts from tests 'WORMATION <br />'kCIL V <br />'FAC �1�xr Datr of <br />—;;r7 —Vj & M KW I K <br />Addrtw 2501 E- JA( <br />Eopta,,t: HASSAN <br />phone, (tog_) 839-3911 <br />Date Local Agency Was Notified of Testing OXNA MAN` —o <br />Name Of Local <br />3, SPILL BUCKET TESTING IT04)"'A J Av" <br />Test Method Uset <br />X Hydrostatic <br />ter <br />Equipment F'oolution: <br />Test EqvipMent Used. <br />identify Spill Bucket (Ap Tank I <br />I V <br />2 91 <br />DIESEL <br />Number, SroradProdtict, gte) <br />.................... <br />X Direct Bary <br />X Direct Bury <br />X Nrect Bur):............. Bury <br />Bucket installation Type- <br />u Contained In Sum <br />U Contained In Sum <br />u Contained in Sum i__Contained in Sum <br />Bucket Diameter: <br />12" <br />12" <br />IT, <br />--� <br />Bucket Depth� <br />i 14" <br />)4" <br />29, <br />wait time between applying <br />I -S MINUTES <br />15 MINUTES <br />15 M I UTES <br />vacuumiwater and start of test'. <br />-- <br />Test Start Time (TI); <br />9M AM <br />9:00 AM <br />9:00 AM <br />Initial Reading (RE): <br />1Y <br />1 13-s <br />191, <br />Test End Time (Te), <br />10.00 AM <br />9 10:00 AM <br />10:00 AM <br />Final Reading (Rr). <br />101, <br />IT' <br />19" <br />Test Duration (Tr — Tj)N <br />I HR <br />I HR <br />I 14R <br />Change in Reading (Rp - RO: <br />3 <br />0 <br />PavFail Threshold or <br />0 <br />0 <br />0 <br />criteria: <br />Test Result- <br />t -i Pass X FAII <br />X Pass 0 Fau <br />0 P;; 0 �Fao <br />CoInments — (include in artnatirrn ran re airs sradc rarer rAtestl , aredrecsa gnder#,rdtirass•zt t r jelled lases) <br />CERTIFICATION OF TECHNICIAN ;tESPONSIBLE FOR CONDUCTING THMTESTINC <br />lhemby certify akar ajjthe jfff0r0WWn contalgedl# berg report iv true, accurate, acrd infol! compliance With legal requirentents. <br />Technician's Signature: <br />!t!!� <br />State laws and regulations do not currently Mquire toting to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />