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SWRCB,January 2006 <br /> Spill Bucket Testing Report 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 @"applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACUXJFY MORMATION <br /> Facility Name: I Date ofTestiz�g: �— <br /> Facility Address: , <br /> Facility Contact: Ph—one: <br /> L <br /> ate Local Agency Was Notified of Testing: <br /> ame of Local Agency Inspector(rf present during testing): C,v,,r- <br /> x. 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. ❑SWRCB Tank Tester ❑Other(S eci <br /> License Number(s), 846288 1064273-UT _ - _ <br /> 3. SPILL BI.7CKET TESTING INFORMATION <br /> Test Method Used: x Hydrostatic El Vacuum ❑Other <br /> Test Equipment Used: DP �'' �ia.t.. Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 ` 23 f 4 <br /> Number,Stored,Product, etc. ! - <br /> Bucket Installation Type: ❑Direct Buy ❑Direct Bury 0 Direct Bury ❑Direct Bury <br /> ❑Contained im Sum Cl Contained in Sunip ❑Containcd in Sump ❑Contained in Sum <br /> Bucket Diameter- <br /> Bucket Depth: ~ <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T): <br /> Initial Reading(R): <br /> Test End Time(Tr): <br /> Final Reading <br /> Test Dw-adon.(Tr—T); <br /> change in Fwadnag(Its-Rr): <br /> Pass/Fail Tbureshold or <br /> Criteria: <br /> lest Result: y 'P ss ElF�ail *Pass CJ Lail t1 F03 ❑Fail ❑ Pass ❑Fall <br /> COmment..S— include information on repairs made prior to testing, and recommended follow-up for fatted tests) <br /> CIIRTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this re is true,accurate,and in fall compl#a"CO with legal rquirements_ <br /> Technician's Signature: <br /> ' <br /> Stat,-laws and regulations da not cu require testing to he performed by a gaali&ed contractor.Hdwever,local reclurezisents <br /> may he more stringent. <br />