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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 USTspill containment structures. The completed form and <br /> printouts from tests(if applicable),should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:Mid Pity Ca FOen Date of Testing-2016-09-01 <br /> Facility Address:13850 Devrles Road <br /> Facility Contact*Jona#=Pakele Phone'(916)439-6042 <br /> 'ED <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> L.tj lji <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:SunWest EWipsering Const.,Inc. � <br /> 4EALTH <br /> Technician Conducting Test David Smith ffz N V 1 R 0 t 7 t7 711 A L! <br /> 5;d=fidsT [1CSLBContractor OICC Service Tech. [1SWRCBTank Testier [3Mer(Spedfy),..,._ . <br /> License Numbers)-8260473 <br /> .3. SPELL BUCKET TESTING INFORMATION <br /> Test Method Used: ®A static ovacuum. []Other <br /> Test Equipment Use&tape messuns I visual Equipment Resolution: <br /> Identity Spill Bucket(By Tank 1 Tank 1 2 3 4 <br /> Number,Stared Product,etc.) <br /> Bucket installation Type: [31*cd Bury ElDirect BuryElDirectBury ElDirect Bury <br /> (Contained in SMp OContained in,2�M.UContained inSump Contained in SUMP <br /> Bucket Diametw. Ir <br /> Bucket Depth: <br /> Wait time between applying 15 <br /> vacmun/vadw and start of test min <br /> Test Start Time(TO: 4900am <br /> Initial Reading(RJ: .5 <br /> Test End Time(TF): 1000am <br /> Final Reading(R): .5 <br /> Tat Duration(Tp—Ti): 1h <br /> Change in Reading(ItF-Rj): 0 <br /> Passfflail Threshold or .0 H <br /> I Criteria: <br /> Test-Resulti OFs a <br /> Pass QFall Pass Fail <br /> Comments—rwcJude!5itMahon on re zurs made Mor to testin ,.and recommended offins-!Eforfailed 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 S Date:2016-09-01 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent <br />