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0 0 120916-022 <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />Ais form Is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br />printoutsfran; tests (if applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br />2. TESTING CONTRACTOR INFORMATION <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: Hydrostatic <br />Test Equipment Used: Visual/ measurement <br />Identify Spill Bucket (by Tank <br />Number. Stored Product, etc. <br />Diesel fuel <br />Bucket Installation Type: <br />t Bury <br />in <br />nt in §!fa <br />k2" <br />Bury <br />maimed in sump <br />*.p <br />sectBuryirect <br />tarsal <br />d Sump <br />Bury <br />ntai <br />'nod in Sump <br />EF <br />Bucket Diameter: <br />1 <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water am start of test: <br />-13" <br />15 mins <br />Test Start Time (Ti): <br />10:30arn <br />Initial Reading (R1): <br />12.5" <br />Test End Time (T <br />.F): <br />11:30arn <br />Final Reading (RF): <br />12.5" <br />Test Duration ('Tr- Ts): <br />one hour <br />Change in Reading (R r Rs}: <br />0.000" <br />Pasafflail Threshold or <br />0,000" <br />W6_ <br />12 -71' "17 <br />Comments - (include in <br />formation on repairs made prior to testing, and recommended follow-!Efar failed tests) <br />QA/QC APPROVED <br />9/28/20124:18 PMBrandon <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the Information contained In A isIs &4 Uaccurate, and in full compliance with legal requirements. <br />D44�sqnd4RAoBexrArr#191H22 <br />Technician's Signature: SIV201210:49 Date: 9/11/2012 <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 />