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SWRCB, January 20t6 Sigill Bucket Testing ReDort Forn This form is intended for use by contractors performing annual testing of LIST 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: (Gw 6 v Date of Testing: C c,Z67 Facility Address: 5-6 (mss 1 74 Facility Contact: P, 41- 4- Phone: Date Local Agency Was Notified of Testing : e jZo Name of Local Agency Inspector (tf present during testing): r� , 014 e /'le ,y�cyy, e -V 3. SPILL BUCKET TESTING INFORMATION Test Method Used: [x] Hydrostatic ❑ Vacuum Q Other Test Equipment Used: Caldwell Level Change Indicator IdentifySpill Bucket (By Tank 1 Number, Stored Product, etc.) Bucket Installation Type: direct Buryirect 11 Contained in S!!mp 2 Bury ❑ Contained in Sl!!np Equipment Resolution: 3 erect Bury 0 Contained in SMTp .0025- 002S"Identify 4 ❑ Direct Bury Q Contained in Sum Bucket Diameter: i Z [ 2 z Bucket Depth: / i r .z Wait time between applying vacuum/water and start of test: .cam a G Test Start Time (T�: > Z t Initial Reading (Ri : Test End Time (TF): Final Reading (RF): Test Duration (TF - TO: `` h r % h �- Change in Reading (RF - Ri): Pass/Fail Threshold or Criteria: Comments — (include information on repairs made prior to testing, and recommended follow-up far failed tests) CERTIFICATION OF TECHNICIAN 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: �--�-�-� Z �` Date: ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.