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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 />FacilityName: t O r A t C, Date of Testing: -7 - 0 <br />Facility Address: ZZf AqM-Mp �0 <br />Facility Contact: q 0 a Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing) <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: G= <br />Technician Conducting Test:C lyl X <br />Credentials: E CSLB Contractor ?'fCC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s)- f Lf 0 (( cI 2 U -t-- <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: drostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: I Equipment Resolution: <br />Identify Spill Bucket (By Tank I <br />Number, Stored Product, etc.) 8'7 <br />Bucket Installation Type: 9?6ufect But- <br />❑ Contained in Sump <br />2 3 <br />j j'` e <br />9,T51rect Buts 91Sirect Burg <br />❑ Contained in Sump ❑ Contained in Sunt i <br />4 <br />❑ Direct Bute <br />❑ Contaitied in Sunt <br />Bucket Diameter: 12- e t <br />1," 1 2- e <br />Bucket Depth: ` <br />13 " 1 r r <br />Wait time between apply in« <br />acuumA ater and start of test: / t't <br />1 d t 1® �• <br />Test Start Time (Tj): (3 OC) <br />Oro <br />Initial Reading (Rt): / ( ` ` <br />1 i t <br />Test End Time (TF): 0 e �G <br />(3130 <br />Final Reading (RF): ( t r <br />/ r f <br />Test Duration (TF - T,): e9 Mi A <br />Change in Reading (RF - RI): <br />- <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: Pass n Fail <br />oe <br />i4ass ❑ Fail ❑ Pass ❑ Fail <br />❑ Pass ❑Fail <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION 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: -3 --2 `0 % <br />` State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />may kA mnro etrinnPnt <br />