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SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is inlendedfor 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 oitmer/operator for submittal to the local regnrlatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Verizon -Manteca CO Date of Testing: <br />Facility Address: 430 West Center Street <br />Facility Contact: MASOOD CHOUDHURY Phone: (909)674-2112 <br />Date Local A enc Was Notified of Testh : 8/25!2011 <br />Name of Local Agency Inspector (if present diming testing): Muniappa Naidu <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: SUNWESF ENGINEERING INC, <br />Technician Conducting Test; TODD HANSEN <br />Credentials: CSLB Contractor( ICC Service Tech.0 SWRCB Tank TesterL] Other (Specifj) <br />License Number(s): 8045710 -UT <br />3. SPILL BUC-V.ET 14 ' <br />Test Method Used: HYDROSTATIC <br />Test Equipment Used: WATER <br />Identify Spill Bucdet (by Zany: <br />hrunrber Stored Product etc. <br />1 Diesel Fuel <br />2 3 4 <br />Bucket Installation Type- <br />Direct Bury <br />Contained in Sum <br />❑ Direct Bucy []Direct Bury ❑ Direct Bury <br />L]Cont inedinSump ❑Contained in Sump ❑Contained in Sum <br />Bucket Diameter; <br />10.5" <br />Bucket Depth: <br />10.5" <br />Wait time between applying <br />vacuum/water and start of test: <br />15 minutes <br />Test Start Time (Tr): <br />1:30pm <br />Initial Reading (Rr): <br />1.5" Below Grade <br />Test !End Time (TF): <br />2:30pm <br />Final Reading (RF): <br />1.5" Below Grade <br />Test Duration (TF- Tl): <br />60 minutes <br />Change in Reading (RF- Ri): <br />0" <br />Pass/Fail Threshold or <br />Criteria: <br />0,000" <br />sN�.,;� <br />w'r B.". UI r ...:+x x ., z <br />J _ �t c t � r -_ <br />�: }. rifi '+� '�C; :� : y3, :4" �x,y�'ry 1 .. ?:L -_ �< ri»'�� �,�.x� � k�ahS nwT .�"1} • !' iaF,?-,a. <br />Comments - (include information on repairs made prior to testing, and reconn)rended follow, -rip for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the igforrnafion container) in Otis report is trite, accurate, and in full compliance with legal requirements. <br />Technician's Signature:_ --" Date: f �y�ZC l 7 - <br />State <br />State laws and regulations do not curren.., .-quire testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />