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E0 <br />SWRCB, January 2006 <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 fol' submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />2. TESTING CONTRACTOR INFORMATION <br />3. SPILL BUCKET TESTING INFORMATION <br />...._....--.--- <br />Test Method Used: drostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: 42a fctW a (( I Equipment Resolution: <br />Identify Spill Bucket (By Tank 1 <br />Number, Stored Product, etc.) <br />21DBucket Installation Type: irect Bun <br />❑ Contained in Sunt p <br />2 <br />irect Bun <br />❑ Contained in Sum <br />3 <br />XD c C <br />B Direct Bun- <br />❑ Contained in Sulu <br />4 <br />❑ Direct Bute <br />❑ Contained in Sunt <br />Bucket Diameter: I -L ` ` <br />1 Z " <br />2 t/ <br />Bucket Depth: t 17!• <br />7 a <br />19 e o <br />Wait time between applying <br />vacuuni/water and start of test: 1 ` <br />t rt <br />14 <br />Test Start Time (Ti): /0.3 L) <br />1 j U O <br />1/ 3 v <br />Initial Reading (Rj): I <br />Test End Time (TF): 1100 <br />1 t3 <br />0 v <br />Final Reading (RF): // <br />zi <br />Test Duration (TF — Ti): 2 j, ✓- <br />/31/' <br />f ,� <br />Change in Reading (RF - Rt): <br />Pass/Fail Threshold or <br />Criteria. <br />Test Result::IL8�Pass ❑ Fail <br />Pass ❑ Fail <br />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 />1 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: 1 1 Ci <br />' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />mov tw mnrP ctrina"t <br />