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SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (f applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. i 1. FACILITY INFORMATION Facility Name: r G Date of Testing: Facility Address: Facility Contact: Phone: Date Local. Agency Was Notified of Testing: Name of Local Agency Inspector (ifpresent during testing): Company Name: u, .,.. I-//" . Technician Conducting Test:'1321,E �k Credentials': 0 CSLB Contractor OICC Service Tech. 0 SWRCB Tank Tester 0 Other (Spee) License Number(s): 3. SPML BUCKET TESTING INFORMATION Test Method Used: OHydrostatic 0 Vacuum 0 Other Test Equipment Used: Equipment Resolution: Identify Spill Bucket (By Tank Number, Stored Product, etc) 1 2 3 4 Bucket Installation Type: 0 Direct Bury Contained in Sum 0 Direct Bury 0 -Contained in Sum 0 Direct Bury 0 Direct Bury &C--ontained in Sum e-eontained in Sum Bucket Diameter: Bucket Depth: Wait time between e acuum/watr and tart applying est: > �° Test Start Time (Ti): 7,.. Initial Reading A): Test End Time (TF): Final Reading (RF): Test Duration (TF — T): / !r; — Change in Reading (Rx - RI): Pass/Fail Threshold or Criteria: Test Result: "ass ❑Fail 0- Pass 0 Fail [Pass ❑Fail 13 Pass ❑Fail Comments — rnclude information on repairs made prior to testing and recommended follow-up forfailed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING j I hereby certo that all the information contained u: this report is true, accurate, and In full compliance wUh legal requirements. 1. J t Technician's Signature: Date: ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, Iocal requirements may be more stringent.