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19255517888 Main Fax GETTLER RYAN INC 10:09:12 a.m. 01-02-2007 212 SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of USTspill 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 2. TESTING CONTRACTOR INFORMATION Company Name: Technician Conducting Test: r Credentials': ❑ CSLB Contractor M -We Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) License Number(s): 3. SPILL BUCKET TESTING INFORMATION 'Test Method Used: Facility Name: e j Qt Date of Testing: % L - Z6 ❑ Vacuum Facility Address: A1A1U~ CA - Test Equipment Used: „3~ Facility Contact: /Y risy -.6 Phone: e49 _,3 �t Date Local Agency Was Notified of Testing Identify Spill Bucket (By Tank Number, Stored Product, etc.) Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Technician Conducting Test: r Credentials': ❑ CSLB Contractor M -We Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) License Number(s): 3. SPILL BUCKET TESTING INFORMATION 'Test Method Used: N;��s`tatic ❑ Vacuum ❑ Other Test Equipment Used: „3~ ,Q�q Equipment Resolution: ..-� Identify Spill Bucket (By Tank Number, Stored Product, etc.) 1 "-I& 2 3 4 Bucket Installation Type: NJ Bury ❑ Contained in Sump ❑ Direct Bury ❑ Contained in Sump ❑ Direct Bury ❑ Direct Bury ❑ Contained in Sump ❑ Contained in Sum Bucket Diameter: ®y Bucket Depth: 4` Wait time between applying vacuum/water and start of test: Test Start Time (Ti): �D® Initial Reading (R,): / Test End Time (TF): Final Reading (RF): /a Test Duration (TF - Ti): Change in Reading (RF- Ri): o Pass/Fail Threshold or Criteria: c Test Result: Pas ❑ Fail ❑ Pass ❑ Fail 0 Pass ❑ Fail ❑ Pass ❑ Fail Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) u`t" l SC1 /4/ 4r7:e- a , , ,,C� r CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: _,�.•-- ___Jrc2-^�--�_ _ Date: _jZ C -- State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.