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, f <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 owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: valet'® Date of Testing: 1-28-11 <br /> Facility Address: 100140" Manteca 95336 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local A en Ins ector Wesent durin testin <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com an Name: !JW_ <br /> Technician Conduetin Test: d4{1 l 11 <br /> Credentials': U CSLB Contractor Y1CC Service Tech. U SWRCB Tank Tester U Other C&Ecify) <br /> License Number(s): ff9520t 'r <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used drostatic U Vacuum U Other <br /> Test uipment Used: Equipment Resolution: <br /> Identify Spill Bucket{By Tank 1 8-1 2 Ott 3 D e es3eA 4 <br /> N b r Stored Produc etc <br /> Bucket Installation Type: WDirect Bury Direct Bury WE1"irect Bury U Direct Bury <br /> U Contained in S U Conftined in Sum U_ConWned in LuM U g9g§jad <br /> ju Sump <br /> Bucket Diameter: fill, <br /> Bucket Depth: 11 V2. <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(r): C:LSr4:15' <br /> Initial Reading(R).- <br /> Test <br /> R):Test End Time(TF): <br /> Final Reading(RF): 12 3/ 123/41 l 1/ <br /> Test Duration F-h: 1.p h o by <br /> Change in Reading(RF-Iii}: d D U <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test telt: Fad! fflfass 0 Fail ss C Fan 0 Pass 0 Fail <br /> COmments—(include information on repairs made prior to testing and recommended follow-up for failed rests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the Information contained in Ah report Is true,accurate,and In full conydiance with legal requirements: <br /> Technician's Signature: CA— Date: 1-28'31 <br /> '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 />