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Spill Bucket Testing Report Form SWRCB,January 2006 <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(tf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: -� <br /> Facility Address: Date of Testing: <br /> < <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: U.S.T. Compliance Testing Inc. <br /> Technician Conducting Test: Tony Fontana <br /> Credentials': IACSLB Contractor 65KICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify <br /> License Number(s): 846288 12-7-;-UT - <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic ❑Vacuum ❑Other. <br /> Test Equipment Used: IN-CON TS-STS Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 1 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: Direct Bury Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Surap ❑Contained in Sum <br /> Bucket Diameter: 1 <br /> Bucket Depth: 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Til: G <br /> Initial Reading(Ri): l �� <br /> Test End Time(TF): <br /> Final Reading(RF): t <br /> Test Duration(TF—TO: `yam <br /> Change in Reading(RF-R,): —,W <br /> _ <br /> Pass/-ail Threshold or , <br /> Criteria: —'�CY-5-D' <br /> Test Result: ePass ❑Fail ass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑F" <br /> Comments—(include information on repairs made prior to restin , and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certify that all lite information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signat <br /> Date+—LV— <br /> ' State laws and regulations o currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />