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SWRCB, January 2006 pill Bucket Testing Report For This form is intended for use by contractors performing annual testing of UST 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. 2. TESTING CONTRACTOR INFORMATION ENVIRONMELIJAI Company Name: Belshire Environmental Services, Inc. Technician Conductinje Test: David Walker Credentials': R1 CSLB Contractor El ICC Service Tech. ❑ SWRCB Tank Tester Ll Other (Spec) License Number(s): 808313 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ❑d H drostatic ❑ Vacuum ❑ Other Test Equipment Used: Visual Equipment Resolution: Identify Spill Bucket (By Tank Number, Stored Product, etc. Bucket Installation Type: 1 DSL Direct Bury 2 3 4 Bucket Diameter: 14" Bucket Depth: 12" Wait time between applying vacuum/water and start of test: 5 Min Test Start Time (TI): 08:00 AM Initial Reading (RD: 11 Test End Time (TF): 09:00 AM Final Reading (RF): 11 Test Duration (TF — TD: 1 Hour Change in Reading (RF - RI): 0.0000 Pass/Fail Threshold or Criteria: No Visual Loss Test Result: ❑d Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑Fail Comments — (include information on repairs made prior to testing, and recommended follow-up for 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:. �✓- Date: 1/7/2015 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.