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Work Ordef: 2249432 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> 7ha form is WanAd far use by contractors performing a inial rating of USTvpill eontai unm siructrres.7U completed form and <br /> printouts from tests(ff applicable),should bt provided to the facility ownerloperwor for submittal to the local regulawy ogee-y- <br /> 1. FACILITY UNFO MA'ffON <br /> Fatality Name: I)Ste of TCStutg: �. / <br /> Facility Address: <br /> Facility Contact: phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(tfprwtW during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: <br /> Credentials': B ConywWr ❑TCC Service Tech. D SWRCB Tank.Tester ❑Other(Specify) <br /> Liteme Number(s): 2 1316, 0 <br /> 3. SPELL BUCEET TESTING INFORMATION <br /> Test Method Used: ❑H dmstatic 0 Vacuum ❑Other <br /> Test Equipment Used: Equipment R esolutitn: <br /> lderrtify Spill Bucket(By Tank 1 2 l.3 3 f J � 4 <br /> Number,SforedEte&2&tta /f P tN <br /> Bucket Installation Type: %DbW Bury Q49red Bury )Mired Bury ❑Direct Bury <br /> ii Contahmi in sump ❑Con>a�in sum D Contained in sum p Conta#ned in Sumv <br /> Bucket Diameter: t L s <br /> Bueket Depth: I Il l 61 <br /> Wait time between applying <br /> vecuumlwater and start of test: <br /> Test Start Time(TO: I d f.1,0 <br /> Initial Reading(Tt,): D '' `• <br /> Test End Time(TF): <br /> Final Reading(RF): <br /> Test Duration(TF—Tt}: <br /> Change in Reading(RF-R)- <br /> Passffiai)Threshold or ! ) <br /> Criteria: �f rr <br /> Test luadt I °Psoas . a IRWI' larrms .0 im ❑Fall� . <br /> Comments--(indade i n on repafrs made prior to testing,and llo failed tests <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that am Ike ltred in tkls relwrt is&me,awgraft and in fayff emVikncee with fo& <br /> Technician's Sigoatvre• Date:_ f <br /> r State laws arras regulations do not eumm9y require testing to be perfa med by a qualified contra=.Howe: local requirements <br /> may be nwre Stringent <br /> Tanknology Inc. 8501 N.MoPac Expressway,Suite 400,Austin,Texas 78759 <br />