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MAR 2 1, 2016 SWRCB,January 2006 <br /> EINIVRONINIE TAT Spill Bucket Testing Report Form <br /> iris rtri►i'1s Fhte►idgd for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> erator for submittal to the local regulatory agency. <br /> printouts from tests(if applicable), should be provided to the facility owner/op <br /> 1. FACILITY INFORMATION <br /> Facility Name: 1 l�1. Date of Testing: • .. <br /> Facility Address: S " f1 C.(1 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): lEt4Mew <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. 0 SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 846288 1064273-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: x Hydrostatic 0 Vacuum ❑Other <br /> Test Equipment Use—�^�." f ST VAP, Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc) <br /> Bucket Installation Type: 0 Direct Bury ❑Direct Bury 0 Direct Bury ❑Direct Bury <br /> IU Contained in Sump A Contained in Sump W Contained in Sump 0 Contained ui Stun <br /> Bucket Diameter: `I `j V <br /> Bucket Depth: L411 1/ W <br /> Wait time between applying <br /> vacuum/water and start of test: (30 <br /> Test Start Time(Ti): L to , 16 1 Lo 6 <br /> Initial Reading(Ri): <br /> Test End Time(TF): 4� <br /> Final Reading(RF): t � 1 94 1 DV Z 6 <br /> Test Duration(TF-Tj): <br /> Change in Reading(RF-RD: —1) 17 ..� <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: Pass ❑Fail Pass 0 Fail Pass ❑Fail At Pass 0 Fail <br /> Comments-(include information on repairs made prior to testing, and recommendedfollow-up for failed tests) <br /> CERTIFICATION OF TECI-IMCIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby cert60 that all the information contained br this report is true,accurate,and in full compliance whit legal requirements. <br /> Technician's Signature: Date: *0,.•{kv,- <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 /> ©T,,S'd 96ZT-T2S-602 9hJIl93l'dw0D,isn:WOdd Sb:�-O 9T02-6T-c1dW <br />