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S WRCB,January 2006 <br /> Spill Bucket Vesting Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The compleled form and <br /> printouts from tests(r(applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION Date Name: Date of Testing, <br /> Facility Address: 'IVM c-31 PEA _HrmAprc, <br /> Facility Contac:): Pp, Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(f'present during testing): FC4A.1, <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: U.S.T,Com fiance Testing Inc. <br /> Technician Conducting Test: Tony Fontana <br /> Credentials': x CSLB Contractor x ICC Service Tech. 0 SWRCS'yank Tester ❑Other(S ecify <br /> License Number(s): 846288 1064273 UT <br /> 3. SPILL BUCKET TEST.TNG MORMATION <br /> Test Method Used: x Hydrostatic 0 Vacuum ❑Other <br /> Test Equipment Used; Equipment Resolution: <br /> ldentify Spill Bucket(By Tank 1 ` 2 3 4 <br /> Number, Stored Product, etc.) 61) <br /> "L l <br /> Bucket Installation Type: Direct Bury a Direct Bury d Direct Bury 0 Direct Bury <br /> Contained in Sump KYConmined in SuM2 Xcontaineoin Sume 0 Contai ed in Sum <br /> _Bucket Diameter: 12 ' ' <br /> Rucket Depth: ) I Zr� <br /> Wait time between applying <br /> vacuum/water and start of test; Q <br /> Test 5utrt Time(Tt); <br /> Initial Reading(17,): •' j <br /> Test End Time(Ta): rdSO <br /> Final Reading(RF): <br /> Test Duration(TF—Tl): <br /> Change in Reading(RF-RI): _ 1D — 10 <br /> pass/Fail Threshold or v — <br /> Criteria, <br /> Test Result: JQ Pass ❑Fail ji Pass ❑Fail pass 0 Fall Pass 0 Fail. <br /> COIl1111ept9—(include in on repairs made prior to testing, and recommended 'allow-u sts <br /> HEALTH <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby cef(&that all the injonnation contained is repo true,accurate,and In fug compliance with legal requlrementc. <br /> Technician's Signature: Dato <br /> ' State laws and regulations do not current y require testing to be performed by a qualified contractor.I-Iowevor, local requirements <br /> may be more stringent. <br /> S S'd 22t7289t7:01 96,LTTES602 99NUI-1dW00 1Sn:W0ad S2:60 bT02-22-dUW <br />