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S WRCB,January 2006 <br /> Spill Bucket Vesting Deport Form <br /> This form is intended for use by contractors performing annual testing of LIST spill containment structures. The completed form and <br /> ;printouts from tests("if applicable), should be provided to the facility owner/vperutor for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: GCS Date of Tes ' l� <br /> Facility Address: Q rl <br /> Facility Contact: i,f Phone: <br /> Date local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): C <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: U.S.T.Compliance Testing Inc. <br /> Tecbnician Conducting Test: Tony Fontana <br /> Credentialsi: x CSLB Contractor x ICC Service Tecb- 0 SWRCB Tank Tester 0 Other(Specify) <br /> License Number(s): 846288 1064273-UT <br /> 3. SPILL B1TCKET TESTING INFORMATION <br /> Fest Method Used: x Hydrostatic 0 Vacuum G Othcr <br /> Test Equipment Used: - Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 � 2 3 F I 4 <br /> Ct <br /> Number,Stored Product, etc.) IFI <br /> Buckct Installation Type: 0 Direct Bury ❑Direct Bury 0 Duct Bury 0 Direct Bury <br /> ,<Contained in Sunip Contained in Sum XContained in Swnp KContained in Sum <br /> Bucket Dikmeter -z r <br /> Bucket Depth: l4 <br /> Wait time between applying <br /> vacuum/water and start of test: f <br /> Test Start Time(Ti): L W L 00 <br /> Initial Reading(RI): Lit1 / <br /> Test End Time(Tr): (� <br /> Final Reading(RF) <br /> Test Duration(TF—TJ): iha& h <br /> Change in Reading(RF-Itt j: <br /> PassNail Threshold or v - O O <br /> Criteria: <br /> Test.Result: Pass 0 Fail 8 Pass ❑. ' -Pas5` <br /> COMMUN—(include information on repairs made prior to testing, and recommer)dedf011OW�up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIRLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the Information contained in this report Is true,accurate,and in fall compliance with legal requirements. <br /> Technician's Signature: Date. '-5 •-lt• i M <br /> State laws and regulatiot,.s do not currently.require testing to be performed by a qualified contractor.However,local requirernmts <br /> may be more stringent. <br />