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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 />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ®Hydrostatic 11 Vacuum 11 Other <br />Test Equipment Used: Measuring Tape <br />Equipment Resolution: Visual <br />3 <br />4 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 91 <br />❑ Direct Bury <br />X Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Installation Type: <br />❑ Direct Bury <br />® Contained in Sump <br />Bucket Diameter: <br />12" <br />12" <br />Bucket Depth: <br />16" <br />16" <br />Wait time between applying <br />vacuum/water and start of test: <br />15 Minutes <br />15 Minutes <br />Test Start Time (TI): <br />9:15 am <br />9:15 am <br />Initial Reading (RI): <br />141/2"Test <br />End Time (TF): <br />5 am <br />10:15 am <br />Final Reading (RF): <br />r14/2 <br />/2 <br />141/2Test <br />Duration (TF — Tj): <br />r. <br />1 Hr. <br />Change in Reading (RF - RI): <br />0.00 <br />0.00 <br />Pass/Fail Threshold or <br />Criteria: <br />0.00 <br />0.00 <br />Test Result: <br />© Pass ❑ Fail <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended folloly-rrp for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THI5 TESTING <br />I hereby certify that all the irtforrrtation contained in this report is true, accurate, mrd in full compliance with legal requirements. <br />Technician's Signature <br />� 08 23 2018 <br />State laws and regulations <br />may be more stringent. <br />do not currently <br />require testing to be performed by a qualified contractor. However, local requirements <br />