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• 0 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 /> I, FACILITY INFORMATION <br /> Facility Name: 4(-Gt4 r- Date of Testing: ;l • PS'-o I <br /> Facility Address: <br /> Facility Contact: Phored <br /> Date Local Agency Was Notified of Testing; <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com an Name: 2 '�T <br /> TwImieiaa Conducting Test; , i3r ora <br /> Credentials': 0 CSLB Contractor NCC Service Tech. 0 SWRCB Tank Tester 0 Other(Spec) <br /> License Number(s): - 7 p$-k- <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: IO Hydrostatic 0 Vacuum C Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 ( 2 L `T 3 4 <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: 0 Direct Bury 0 Direct Bury 0 Direct Bury 0 Direct Bury <br /> Contained in Sum 9'Contained in Sum l:Contained in Sump ❑Contained in Sum <br /> Bucket Diameter. <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T,): <br /> Initial Reading <br /> Test End Time(TF): <br /> Final Reading(RF): f/ f t . . <br /> Test Duration(TF-TO: ,. ;✓ v <br /> Change in Reading(RF-RD: <br /> Pass/Fail Threshold or <br /> Criteria: , <br /> s - 7 tila , ,t#t: <br /> Comments-(include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECBNICL4N 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 /> Techtlldlan's Signature:. <br /> DaW <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br /> maybe more stringent. <br />