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1.r N%w 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 /> Facilit,Name: VZB-LDIKCA Date of Testing: 5/17/12 <br /> Facility Address: 2500 W.Turner Rd. <br /> Facility Contact:Jonathan Pakele Phone:916-439-6042 <br /> Date Local Agency Was Notified of Testing: 48 Hours Prior <br /> Name of Local Agency Inspector(i resent during testing): Aris Cacapit <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Sunwest Engineering Inc. <br /> Technician Conducting Test: Paul McLane <br /> Credentials : CSLB Contractor❑ ICC Service Tech. SWRCB Tank Tester❑Other (Specify) <br /> License Number(s): 5238651-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Standard Lake Test <br /> Test Equipment Used: None <br /> Identify Spill Bucket(by Tank I DSL FILL 2 3 4 <br /> Number Stored Product, etc. <br /> Bucket installation Type: Direct Bury Direct Bury L]Direct Bury ❑Direct Bury <br /> ❑Contained in Sum L]Contained in Sum L]Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 121- <br /> Bucket <br /> 2"Bucket Depth: 14" <br /> Wait time between applying 15 MIN. <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:15 AM <br /> Initial Reading(RI): 12.5" <br /> Test End Time(TF): 10:15 AM <br /> Final Reading(RF): 12.5" <br /> Test Duration(TF-Tj): 1 Hour <br /> Change in Reading(RF-Rj): 0" <br /> Pass/Fail Threshold or 010 <br /> Criteria: <br /> Comments- (include information on re airs made prior to testing, and recommendedfollow-up or ailed tests <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: C Date:5/17/12 <br /> 1State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />