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SWl2CB,January 2006 <br /> SpW Bucket Testing Report Form <br /> .This form is intended for use by. 2r_tnactors performing annual testing of UST spill containment structures.The completed form and <br /> printouts from tests(ifapplicab! , should be provided to thefacilay ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: •nLm br L' lr� _ Date of Testing: <br /> Facility Address: 7. j' <br /> Facility Contact >Lt _ T`1.S Ootw1 Phone: <br /> Date Local Agency Was Notified f Testing: <br /> Name of Local Agency Inspector. foreseer during testing}: g.3 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> CompaztyName: ��; �_ <br /> Technician Conducting Test: '!I" �:;Go �w <br /> Credentials': ❑CSLB Contracu' _ Service Tech. 0 SWRCB Tank Tester V0dxr(Specify) <br /> License Number(s): <br /> 3. 33PILA.,BUCKET.TESTING.INFORMATION <br /> Test Method Used: . �;r lI drostatic t3 Vacmun ©Other <br /> Test Egu*mnt Us :� Q��� Egoipment Resolution: 7® <br /> i <br /> Identify Spt71 Becket(By Tank :l ,. Z 3 :4 <br /> Nurn&7;Stored Product,etc. < ' . <br /> e• <br /> Installation Type:. #, Q)uect Bury M=MSUMP <br /> trect Bury Bu[- in SQ Contained in S '0Contained in Sump <br /> Yj <br /> B &- l <br /> Wait tune between applying <br /> vacuumlwater and start of test: _c�!�'� l✓ .� <br /> Test Start Time(Tj): t� <br /> znitsal Reading(R4)= <br /> Test Paid Time.(TF): (S a�t� i 4 <br /> Final Reading(RF): _ _t. ,G; is 'fS' <br /> Test Duration(TF—Ti): <br /> Change in Reading(RF-Rr): <br /> Pass/Fail Threshold or e' u <br /> Criteria: 9 a ' <br /> lac, `it <br /> con meats --(include in ormatia. c n made r to testing,and recommended follou, for ailed tests). <br /> OKI 6i7 <br /> CERTIFICATION d'R ?TFRC.HNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING. <br /> 1 hereby.certify.tkat all the inform, ern.contained inthis.repod is true,accurate,and in.fall compliasm wick legal regniremenft. <br /> Technician' - �«„ J Date: <br /> State Jaws icgulations do not cut ezitly requim testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent <br /> b 'd ZbE9 T 9ipsce l sJ040eW03 AI 8-4T13 e9 T :LO TT 92 idd <br />