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05/19/2008 16:19 2093651 TANKNOLOGY PAGE 09 <br />SWRCB January 2006 <br />Spill Bucket Testing Report Form <br />rAw form is intended fivr we by comractors pmf- crm g annual roti of UST spill coruairm:eni strucWts. The comp etedform and <br />printoms from tests (f applicable), should be provided to the facil ty owner/operaror for submittal to *e local regularry agency. <br />I - xAVn.rr V T?","1Q ►IrATrnN <br />facility Name: C o,y,,, c o , I r I nate of Testigg,: •-t -V <br />Test Equipment Used: Lo <br />Facility Address: i [ , , <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Tending: <br />2 <br />V,$. p " 1 <br />Name of Local Agency Inspector (tfpresbnt during leslingj: 1p, a fj <br />4 <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name �"cc.��st.a %ri <br />Technician Conducting Test: f - s d ---e6/ 1 <br />Credentials': d CSLB Contractor CC Service Taeh, 0 SWRCl3 Tank Tester 0 Other (Sscrfy) <br />License Number(s): "t ? ✓d- - <br />3_ :RVIT,L 11TY-`IMT T%STMC- i1VTiY1127 CMON <br />Test Method Used:H drbstatc 0 Vacuum 0 Other <br />Test Equipment Used: Lo <br />Fxju4mwnt Resolution: <br />Identify Spill Bucket (By Tank 1 f <br />Number, Stored Product, etc) 91 ;tz m ( <br />2 <br />V,$. p " 1 <br />3 <br />4 <br />Bucket Installation Type: ;VDirect Bury <br />O Contained in &mp <br />0 Direct Boxy <br />AContained in Sump <br />0 Direct Bury <br />C Contained in Sum <br />0 Direct Bury <br />0 Contained in Sump <br />Bucket Diameter: <br />Bucket Depth: rr <br />Walt time between applying <br />vacuum/water and start of test:�- <br />Test Start Time (To: 03 <br />: c*) <br />Initial Reading (Rt): <br />)Yq <br />Test End Time (Tr): -03 <br />—/-ti/ <br />Final Reading (PIF) - <br />Test Duration (TF - T')- <br />Change in Reading X Rt): 17 Ll <br />Pass/Fail Threshold or r r <br />Criteria: <br />f t <br />Test R.esidt: Piss . 0 Fail <br />JVPaw Ci Fail <br />. Q Vass D Fail <br />13 Pass ZO ftil <br />Comments — (include inj�ormaaon on repairs made prior to testing and recommended fallow u r failed tests <br />CERTIFICATION OF TtCHNICIAN RESPONSIBLE FOR CONDUCTIN0,THIS'I`ESTYNG <br />I hereby certify that all t' a in, fOrmatiot1. contained in flus reporf is thee, accurate, acrd in firs compliance whir legal <br />Technician's Signature?__ r�� Date: <br />' State laws anal regulations do not curreky require testing to be perfiormed by a qualified contractor. However, local requirements <br />may be more stringent. <br />uiremrenls <br />