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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 /> 4__ Date of Testing: <br /> Facility Name: 1 <br /> Facility Address ')y (A 1hQ <br /> Facility Contact: G crte h Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): C C e,&, <br /> 6-1 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: U.S.T.Compliance Testing Inc. <br /> Technician Conducting Test: Tony Fontana <br /> Credentials': x CSLB Contractor x ICC Service Tech. 0 SWRCB Tank Tester C Other(Specify) <br /> License Number(s): 846288 1064273-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: C Hydrostatic ❑Vacuum C Other <br /> Test Equipment Used: IN-CON TS-STS Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: Direct Bury _Direct Bury C Direct Bury 0 Direct Bury <br /> ❑Contained in Sum 7 Contained in Sum a Contained in Sump 0 Contained in Sum <br /> Bucket Diameter. " <br /> Bucket Depth: '' (k4 <br /> Wait time between applying JON 1� <br /> vacuum/water and start of test: Q_ N1 <br /> Test Start Time(Ti): 05 CZ0 <br /> Initial Reading(Rt): 'Z' " 2 )1(4 i' <br /> Test End Time(TF): 106S I j <br /> Final Reading(RF): V '' c' <br /> TH <br /> Test Duration(TF—T!): DEPARTMENT <br /> Change in Reading(RF-R): <br /> Pass/Fail Threshold or D D <br /> Criteria: <br /> Test Result: j*Pass 0 Fail jd Pass 0 Fail 0 Pass 0 Fail 0 Pass 0 Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> I Alai e -- la)'I¢,L <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this is true,accurate,and in full compliance with legal requirement& <br /> Technician's Signature: Date: <br /> 1 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 />