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• 06-28-'10 14:14 FROM-West Star Envmt Inc. +559-277-0106 T-708 P0007/0007 F-325 <br /> Ask <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This fonn is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> prbitoiuts frons tests(if applicable).should be provided to the facility ownerlope:`tror,(or submittal to the local regulatory agency. <br /> 1. FAGQI.ICTY INFORMATION <br /> Facility Name: bate of Testing: <br /> Facility Address:. Is rA4J& <br /> Facility Contact: Phone: — <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(¢f present during restt►ag): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: <br /> Credentials': CSL$Contractor ICC Service Tech. SWRCB Tank Tower Other!Specify} <br /> License Number(s): <br /> 3. SQL CENT TESTING WORMATION <br /> Test Method Used: klydrostatic Vacuum Other <br /> Test Equipment Used: BquipmeAt Resolution: <br /> Id ndfy Spill Bucket(By Tarok Z 2 3 ® ( d <br /> Nuniber,-Stored Product;etc.} <br /> irect CEO t u Direct u <br /> Bucket Installation Type: Contained in Sum Contained in Sump Contained in Sump Contained in Sum <br /> Bucket Diameter: <br /> RAL <br /> Bucket Depth: <br /> Wait tinse between applying <br /> yacuunilwater and start of test: <br /> Y� <br /> Test Start Time(T& <br /> a ®i rA <br /> L <br /> IF <br /> Initial Reading(Ru): Lew <br /> Test End Time(TF): W1MV <br /> VA <br /> a Q 1 <br /> t <br /> Final Reading(RF): <br /> Tcst Duration(TF—Tt): <br /> Change in Reading10 <br /> (Rr-Rt): <br /> AN <br /> Pass/Fail Threshold or <br /> Criteria: ',r „ryls ' <br /> ! •.`"! ,,, .�-t:v: - ,P`..fie..,t,.... _.. .•M . .. ,, NO <br /> Comments--(include infornwdon on repairs made prior to test and recommended follow-up for failed rests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TICS TESTING <br /> I hereby eet'tify that all the informador ontained in chis report is true,accurate,and in full Compliance with legal requi.mments. <br /> Technician's Sienatura:19 <br /> ae: �_ � <br /> ' State lacus and regulations do not currently require testing to be performed by a qualified contractor.I•Iowe'ver,local requirements <br /> may be more stringent. <br />