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wo <br /> 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:VZB-LDIKCA Date of Testing: 5/17/12 <br /> Facility Address: 2500 W.Turner Rd. <br /> Facility Contact:Jonathan Pakele Phone:91.6-439-6042 <br /> Date Local Agency Was Notified of Testing: 48 Hours Prior <br /> Name of Local Agency Inspector(if present 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.0 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 1 DSL FILL 2 3 q <br /> Number, Stored Product etc. <br /> ;Bucket Installation Type: Direct Bury Direct Bury ❑Direct Bury Direct Bury❑Contaitted in Sum ❑ContainedinSum ❑Contained in Sum ❑Contained in Sumucket Diameter: 12" <br /> 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-Ti): I Hour <br /> Change in Reading(R F-Rj): 0" <br /> Pass/FaiI Threshold or 01. <br /> Criteria: <br /> Test Results Pass <br /> Comments - (include information on repairs made prior to testing, and recommended folloii,-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> J hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: CDate:5/17/12 <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 />