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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 (if 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: <br /> Facility Address: , -t"C2ac <br /> Facility Contact: h Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector('(present during testing): 1 � 4p <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: U.S.T.Compliance Testing Inc. <br /> Technician Conducting Test: Tony Fontana <br /> Credentials': x CSLB Contractor x ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Sped) <br /> License Number(s): 846288 1064273-UT <br /> 3. SPrLL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑x Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Tape Measure Equipment Resolution:1/8 inch <br /> Identify Spill Bucket(By Tank 1 gl 2 A Q L 3 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: b(Direct Bury OdDirect Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: (Z I I <br /> Bucket Depth: 4 <br /> Wait time between applying <br /> vacuum/water and start of test: B <br /> Test Start Time(TI): <br /> Initial Reading(RI): l D 1/4 <br /> Test End Time(TF): [cki) <br /> Final Reading(RF): <br /> Test Duration(TF—TI): <br /> Change in Reading(RF-RI): b _ p <br /> Pass/Fail Threshold or —0 <br /> Criteria: <br /> Test Result:. JZPass ❑Fail Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommen ow ' for failed tests <br /> .a t <br /> ENVIRONMENTAL HEALTI <br /> DEPARTMENT <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 1>" 19 " 11 <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />