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v , <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: .� ~' Date of Testing: _ t 1 <br /> Facility Address: <br /> Facility Contact: ►-N P one: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: U.S.T.Compliance Testing Inc. <br /> Technician Conducting Test: Tony Fontana <br /> Credentialsl: x CSLB Contractor x ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 846288 1064273-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: x Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used 0E-C'@l,Tg3�S —� Equipment Resolution: <br /> Number, Stored Product, a <br /> y . :v <br /> Identify P BY Tank 1 3 4 ' <br /> etc.) � 2 CL � <br /> Bucket Installation Type: Direct Bury irect Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sum ❑Contained in Sum ❑Contained in Sum ❑Contained in Sum <br /> Bucket Diameter: <br /> Bucket Depth: + <br /> Wait time between applying <br /> vacuum/water and start of test: g <br /> Test Start Time(TI): <br /> Initial Reading(R): L ,+ <br /> YZ <br /> Test End Time(TF): —ACRA Ab <br /> Final Reading(RF): t4' <br /> t <br /> Test Duration(TF—TI): <br /> Change in Reading(RF-R): _.-0 Cass/Fail Threshold or —0CriteiaTest Result: l Pass ❑Fail ❑Fail <br /> ❑ Pass ❑lFaill ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-u for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in th' report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: <br /> Date: -2—'—'-� .. <br /> ' State taws and regulations do not currently require testing to be performed by a qualified contractor.H <br /> may be more stringent. <br /> owever, local requirements <br />