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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 UST spill containment structures. The completed form and <br />printouts from tests (if applicable) should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br />Technician Conducting Test: ROB NEIMEYER <br />Credentials': ® CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): 803705 <br />';_ CPTT.T. RTTf KTi.T TTi.CTBNC_ TNVnUX4A'rTniar <br />Test Method Used: <br />® Hydrostatic <br />❑ Vacuum <br />❑ Other (Spec) <br />Test Equipment Used: VISUAL <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Bucket Installation Type: <br />DIESEL FILL <br />® Direct Bury <br />❑ Contained in Sump <br />87 FILL <br />Z Direct Bury <br />❑ Contained in Sump <br />Equipment Resolution: <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />10.50" <br />10.50" <br />Bucket Depth: <br />12.00" <br />12.00" <br />Wait time between applying <br />vacuum/water and start of test: <br />0 <br />0 <br />Test Start Time (TO: <br />9:00 AM <br />9:00 AM <br />Initial Reading (RI): <br />12.00" <br />12.00" <br />Test End Time (TF): <br />10:00 AM <br />9:15 AM <br />Final Reading (RF): <br />12.00" <br />9.00" <br />Test Duration (TF — TI): <br />1 HR <br />15 MIN <br />Change in Reading (RF - RI): <br />0 <br />.3.00" <br />Pass/Fail Threshold or Criteria: <br />TSS#""Result: <br />®Pass ❑ fail <br />❑ Pass " Fail <br />' ❑" `Pass ❑" Fail- ,. <br />" Fass ❑>tl .: <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />REPLACED DRAIN VALVE ASSEMBLY ON 87 -- RETEST FAILED <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 Signature: Date: JUN 5, 2008 <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 />