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REGEIVFr�) <br />' G 13 lan <br />Spill Bucket Testing Report Form RC 20tett15ry 200 <br />This form is intended for use by contractors performing annual i"ming of UST spill contalnment structg i>R@ ,y�d <br />printouts from tt.sa (if applicable), should be provided to the facility owner/operator for submittal to the it Cd17¢gtitaEabdxy�, 4 <br />1. FACTLPITV INFORMATION <br />Facility Name: e'1L a 0 (-- , <br />Facility Address: <br />Facility Contact: <br />Datc Local Agency Was Notifjcd of <br />Name of Local Agency Inspector (if pi <br />MMU <br />Phone: <br />Date of <br />2. 'TESTING CONTRACTOR INFORMATION <br />Com any Name: U.S.T. Compliance Testing tnc, <br />Technician Conducting Test: Tony Fontana <br />Credentials': x CSLB Contractor x ICC Service Tech. D SWRCB Tank Tcstcr D Other (5pceifv,) <br />License Number(s): 846258 1 X64273 -UT <br />a Ci�'1'f .i. RiTf`KF'.T TF:!�"t'tNf' TI�TFtIRMATiI-1NT <br />Test Method Used: x Hydrostatic D Vacuum U Other <br />Test Equipment Uscd: M -CON TS -STS LSNA- Fquipment Resolution: <br />Identify Spill Bucket (9v Tank <br />1 <br />2 c <br />3 <br />4 <br />Number, Stored Product etc.)!1� <br />Direct Bury <br />0 Direct Bury <br />D Direct Bury <br />0 Direct Bury <br />Bucket Installation Type: <br />(J Contained in Sump <br />D Contained iE2Sw-np <br />0 Contained in SLIMP <br />0 Contained in Sum . <br />Bucket Diameter: <br />Bucket Depth: <br />14 S4 <br />i t <br />Wait time between applying <br />- <br />G4vacuum/wate.r <br />and start of test: <br />....... ,., ._.__ <br />Tcst Start Tinie (Ti): <br />-Initial Reading (R): <br />Test End Time (TF); <br />H. .. <br />Fu3al Reading (RF): <br />t 6 <br />Test Duration (fp - T,): <br />ir. <br />Change in Reading (RF - Rt): <br />-- <br />, <br />Pass/Fait' Threshold orr- <br />Criteria: <br />- <br />Test Result. <br />Pass O .%All <br />Pass 0 Fail <br />D Pass Fl Fail <br />0 Pass 0 Fail <br />Comments — <br />CERTIFICATION OF T)ECKNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I herebv cert#ythat all lite infarmarlon contained in thin yjwxtAv tru�yafcurate, and in full congViance with legal requirements. <br />Technician's Signature: <br />t State laws and regulations do not current <br />may be more stringent. <br />IL/1L . d 22b589t7 : 01 <br />ng to be performed by a qualified contractor. However, local requirements <br />962JT2-SG02 30NhI-IdWOD iSn:WOdd T2:9T ST02-241Uf <br />