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im6ErTLER-RYAN INC. GR Job 20-632266 <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The Completed form and <br />printouts from tests (if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br />2. TESTING CONTRACTOR INFORMATION OCT 05 2015 <br />14 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />tivdrostatic <br />Vacuum <br />Other <br />Test Equipment Used: <br />Standard Tape Measurer <br />Equipment Resolution: <br />1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product,etc, <br />1 87 Main Vapor <br />2 87 Slave Vapor <br />3 87 Siphon Vapor <br />4 91 Vapor <br />Bucket Installation Type: <br />Direct Bury <br />Contained in Sump <br />Direct Bury <br />X Contained in Sump <br />Direct Bury <br />x Contained in Sump <br />Direct Bury <br />x Contained in Sump <br />Bucket Diameter: <br />fill <br />13" <br />13" <br />131, <br />Bucket Depth: <br />16" <br />16" <br />16" <br />16" <br />Wait time between applying <br />vacuum/water and start of test: <br />10rain <br />10"lin <br />Iffinin <br />10min <br />Test Start Time (Ti): <br />12:00 <br />12:00 <br />12:00 <br />12:00 <br />Initial Reading (Ri): <br />III, <br />fill <br />IF, <br />fill <br />Test End Time (Tf): <br />13:00 <br />13:00 <br />13:00 <br />13:00 <br />Final Reading (Rf) <br />IV, <br />III, <br />III, <br />III, <br />Test duration (Tf - Ti): <br />I hi- <br />l h r <br />1 h r <br />Ihr <br />Change in Reading (Rf-Ri): <br />0 <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or Criteria: <br />0 <br />0 <br />0 <br />0 <br />Test Results: 11 <br />x Pass Fail I <br />X Pass Fail <br />X Pass Fail <br />X Pass Fail <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements <br />Technician's Signature: Date: 918/2015 <br />(1) State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />