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Mar 02 10 10: 13a Elite TV Contactors 12094616342 p. 3 Spill Bucket Testing Report Form ` 2— 2 This form is intended for use by contractors performing annual testing of UST spill containment structures_ The completed form and printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION. Facility Name: �, Date of Testing: Facility Address: qCO C �L Facility Contact Phone: Date Local Agency Was Notified of Testing: -,C) Name of Local Agency Inspector(if present during testing): 2. TESTING CONTRACTOR INFORMATION. Company Name: - Technician Conducting Test Credentials': CSLB Contractor 16C Service Tech. 0 SWRCB Tank Tester 0 Other(Specify) License L`iumberis): 3_ SPILL BUCKET TESTING INFORMATION Test Method Used: ❑Hydrostatic D Vacuum ❑Other Test Equipment Used: Equipment Resolution: Identify Spill Buct et(By Tank 1 Op _0 �Z 2 3 4 Number,Stored Product, etc. :� y ect Bury 0 Direct Bury 0 Direct Bury 3 Direct Bury Bucket Installation Type: ❑Contained m Sump 0 Contained in Sump ❑Contained in Sump 0 Contained in S Backet Diameter. Bucket Depth: Wait time between applying vacuum/water and start of test: Test Start Time(T): Initial Reading(RO: a v Test End Time(TF): Final Reading(RF): Test Duration(TF-T�: Change in Reading(RF-R): Pass/Fail Threshold or Criteria: : AM COIrim6IItS-(include information on re pairs made prior to testing,and recommended follow-up for failed tests). CERTIFICATION OF TECM141CIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. Technician's Signature: - �- Y Date: State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent.