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Mar 18 10 12:21p Elite Contactors 120946 42 <br />4 40 <br />p.3 <br />ID ---� <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of LIST spill containment structures. The completed form and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatoryagency. <br />. i- vm+c7 YATL 11721A/(A 'rTniv <br />Facility Name: Date of Testing: <br />Facility Address: <br />Facility Contact: fea <br />Phone: <br />Date Local Agency Was Notified of Testing <br />1,TnrnP nfi.nrai Avencv Insnector tiforesent during testing): MOC1Xf Ali' N kAenf-Y <br />TF-STING2. • • . INFORMATION <br />Company Name: a <br />Technician Conducting_Test:IM L <br />Credentials': Q CSLB Contractor SCC Service Tech. ❑ SWRCB Tank Tester C Other (Sped <br />License Number(s): <br />nrynvT V "TTf"T,TVrV rFVVQ'rTATJ' TATTNl1 MAIrYfIX <br />Test Method Used: <br />Hydrostatic ❑ Vacuum <br />Q Other <br />Test Equipment Used: <br />Equipment Resolution: <br />Number, Stored Product, etc. <br />Identify Spill Bucket (Py TanfRury <br />971 <br />z <br />3 4 <br />Bucket Installation Type: <br />irect B <br />ontained in Sump <br />❑ Direct Bury <br />Q Contained in Sump <br />Q Direct Bury ❑ Direct Bury <br />❑ Contained in Sug!p 0 Contained in Sum <br />Bucket Diameter: <br />Bucket Depth: <br />14 °® <br />Walt time peen applying <br />vacuum water nd start of test: <br />Test Start e (T,): <br />Initial Reading (Rj): <br />i 1 "12 - <br />Test End Time (TF): <br />41 <br />Final Reading (RF): <br />l i <br />Test Duration (Tr - Tj): <br />t <br />__ <br />Change in Reading (Rr-RI): <br />Pass/Fail Threshold or <br />Criteria: <br />pc�r <br />[[ <br />Pass>.�y:Q"Faa"� <br />Comments —_(include information on repairs made prior to testing and recommended jotlow-up for )az[ea tests) <br />TL �5ffi WA HCl bGZM0Zt W1116 iftt6 -IfPk -51-ff) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Date:�Cf <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 />