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thCERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />ereby certify that all the information contained in tfiic report is true, accurate, and in full compliance wi <br />th legal requirements. <br />Technician's Signature• <br />Dare: <br />State laws and regulations do not c require testing to be - <br />may may be more stringent. Performed y a qualified contractor. However, local requirements <br />. <br />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 (V applicable), should be provided to the facility <br />owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: tl <br />k <br />Facility Address: <br />Date of Testing: _ _ bb <br />5K� <br />Facility Contact: <br />Phone: <br />Date Local Agency:Was Notified of TestingName <br />of Local Agey Inspector (f present during testing): <br />2. <br />TESTING CONTRACTOR INFORMATION <br />Company Name: U.S.T. Compliance Testing Inc. - ---- -- - <br />Technician Conducting Test: <br />Tony Fontana <br />Credentials: CSLB Contractor .FICC Service Tech. ❑SWRCB Tank Tester ❑ Other S eci <br />License Number(s): 846288 (Specify) <br />�3-UT-� _ ---- -- <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />Test Equipment Used: IN -CON <br />Hydrostatic ❑ Vacuum <br />TS -STS Other <br />Resolution: <br />Identify Spill Bucket (Bv Tank <br />I <br />Number, Stored Product, etc.) <br />3 <br />Bucket Installation Type: <br />''Direct Bury <br />&Direct Bury <br />C Direct Bury <br />Bucket Diameter: <br />❑ Contained in Sum <br />$1 <br />❑ Contained in Sum <br />❑ Contained in Sum <br />❑ Direct B �' <br />❑ Contained in Sum <br />Bucket Depth: <br />i <br />„ <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TO: <br />�ltS <br />Initial Readin'S� <br />Test End Time (TF): <br />4— <br />Reading (RF):/ <br />O <br />Test Duration (TF - T1): <br />h — <br />Change in Reading (RF - R j): <br />_ <br />Pass/Fail Threshold or <br />—� <br />Criteria: <br />—0 <br />Test Result: <br />CO T MCIIts — (include information <br />,Q Pass ❑Fail <br />-L Pass ❑Fail <br />❑Pass ❑Fail <br />❑ <br />on repairs madeprior to restin , and recommended fPass zr for failed tests)Pass_ Fail <br />thCERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />ereby certify that all the information contained in tfiic report is true, accurate, and in full compliance wi <br />th legal requirements. <br />Technician's Signature• <br />Dare: <br />State laws and regulations do not c require testing to be - <br />may may be more stringent. Performed y a qualified contractor. However, local requirements <br />