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Spill Bucket Testing Report Form S WRC$, January 3006 <br />This fbl-m is intended for use by co)itrQCtvrs perf0rMQsg annual testis o UST <br />printUttts from leszs t j,c� - � f spill conrainmer,t structures. The completed form and <br />(f•app ' le), should beprovided toliiefacility owner/operQtorfnr cribmitral ra ihclocal resuluiury agency, <br />-- 1 Y? ♦ nrr Ye— I rti .ti- - - <br />2. TESTING CONTRACTOR FORMATION <br />Company Name- U.S.T. Compliance Tas ' Inc. <br />Teelutician conducting `lest: Tony Fontana <br />Credentials'; 10 CSLB Contractor XICC Service Tech. © SWRCB Tank Tester <br />I •ir.Pnse Number(s): 846.''-.88 4H6+4z�3.LIT��.—x.�-rv�� <br />CERTIFICATION OFTECHN'ICYAN RESPo NS113L'E <br />FOR CONDIIC7YNG THIS TES'i1NG <br />1 i:ereby certefy that all the infurmatior: Contained this report is true, QdGtltn41�, and full compiiarice with regal requirements. <br />9 s <br />1'echnicisn's SignaTUr <br />]Date, - <br />State laws and regulations do not c <br />may be more stringent. require testing to be performed by a quaiifad contta4toz. Iioweaar, local regUireme7,ts <br />90/90 39Vd 0003 Sd9 3NO d 9L9L66860Z 6580 800Z/LZ/0Z <br />3. SPILL BUCKET <br />TESTING- XNFORMATXON <br />Test Ivlcthod Used: <br />li drostatic <br />❑ 'Vacuum <br />❑ Other <br />Test Equipment Used: IN -CON <br />TS -STS <br />Fqiilpm"ntResolution: <br />Identify Spill Bucket (By Tarrk <br />vw fiber, Stored Product, ere,) <br />3 <br />4 <br />Bucket Installation Type: <br />'0Direct Bury <br />❑ Contained in Sunip <br />ODirect Bury <br />❑ Direct Bw y <br />❑ Direct Bury <br />Bucket Diameter: <br />'1 <br />11 Contained in Sunt <br />L7 Contained ire Sum <br />❑ Cnntained in Sun <br />Bucket Depth: <br />�i' <br />Wait time between applying <br />�-�-- <br />yaMWTnJwater &ttd start of test: <br />�I'u <br />_ <br />Test Start Time (T,): <br />b�5 <br />�S� <br />initial Reading (k,): <br />Test End Time (TF): <br />` W- <br />tMal Reading CRP)-- <br />RP):Test <br />TestDw-anon (TF - T,): <br />Change in Reading (Rr- - X): <br />Passxail Thre$,, or <br />Criteria <br />~O <br />o <br />Test Result: <br />COM Qerits — mchide iQ <br />( r forrr�arioir <br />� Pass ❑ )~ail 11 <br />4i Pass 11 Fail <br />0 Pass []]Fall <br />past ❑ I air <br />on re�,airs mads prior <br />to test , and recommended <br />follow-i�p for fatlPd <br />tpCf�: <br />CERTIFICATION OFTECHN'ICYAN RESPo NS113L'E <br />FOR CONDIIC7YNG THIS TES'i1NG <br />1 i:ereby certefy that all the infurmatior: Contained this report is true, QdGtltn41�, and full compiiarice with regal requirements. <br />9 s <br />1'echnicisn's SignaTUr <br />]Date, - <br />State laws and regulations do not c <br />may be more stringent. require testing to be performed by a quaiifad contta4toz. Iioweaar, local regUireme7,ts <br />90/90 39Vd 0003 Sd9 3NO d 9L9L66860Z 6580 800Z/LZ/0Z <br />