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D�_r C 17 <br />Spill Bucket Testing Report FornENVIRONM <br />This form is intended for use by contractors performing annual testing of UST spill containmeM�Al kPW <br />printouts from tests (if applicable), should be provided to the facility awnerinparamr for submittal to the local <br />1. FACILITY INFORMATION <br />Facility Name: Date of Tasting: —1: <br />Facility Address: } <br />Facility Contact: ( Phone: <br />Date Local Agency Was Notified .of Testing <br />Nwne of Local Agency Inspector (f present during testing): C14 A <br />2. TESTING CONTRACTOR. INFORMATION <br />PTechn:i7ciaaCoa&wtjn <br />ame: U.S.T. Compliance TestingInc. <br />g Test: Tony Fontana <br />l: CST.B Co <br />ntlUtar x ICC Service Tech D SwRCB Tank Toster a t7ttner (Spec) <br />mber(s): 846288 1064273 -Ur <br />3. SPtM B1f_1CKKI' TESTING INFORMATION <br />Test Method Used: x Hydrostatic ❑ 'V'acuum ❑ Other <br />Test F.,qutpment Used "Il ? <br />-BIFS^� <br />Identi€y Spill Bucke# ( }' Tank <br />I <br />Nunther, Stor¢d Product, ato. <br />Bucket Installetion Type: <br />J(Drrect ,Bury <br />❑ Contained in Sum <br />Bucket Diameter; <br />I i <br />Bucket Depth: <br />i <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (T,): <br />Initial Reading (Ril: <br />Test Enid Time (Tr): <br />� <br />Final Reading (ltg): <br />Test Duration (TF — T): <br />Change in Reading ft -R4): <br />PasslFai Threshold or <br />—� <br />Criteria; <br />CanumeAts - (include is ormation on repairs made <br />cVIPIU nt xesoiutlon: <br />2 ` 3 4 <br />Direct Bury ❑ Direct Bury ❑ <br />❑ Contained in Sump C Contained iu Sump ❑ <br />i1w�-�J <br />--a <br />IPWM Q Fail. <br />to testinx and recd, <br />0 Pass C3 Fail j El <br />January 2006 <br />iform and <br />agency. <br />In <br />MI <br />CERTIFICATION or, TECHNICLAN REsPONSIBi.E )FQ1t CONDUCTING THIS TF STING <br />I hereby eertijy thpY aa the lnfnrm 'off eank&ed ix this report is <br />arccurnata, and br,%uII comptrattre wt�t Darr r�yuirenrentt. <br />Technician°s Signature: <br />Date: <br />State laws and regulations do not c <br />'"y be more stringent. rewire testing to be perfotmod by a qualified contractor. PloWever, local req ements <br />TTi90 139"d QOOd Sb9 3NO kJ 9L9LEHGQ6 6b:tT ,-:Tt_+1,i�Ti T <br />