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I I I -M <br /> 10-21-'14 13:52 FROM- West Star Envmt Inc. +559-277-0106 T-439 P0005/0006 F-010 <br /> • • SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill cohtainment 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 /> FaciilityName: riLDYij Un�iron Date of Testing: l� 1s1 ltd <br /> Facility Address: a'og ). C A v� C.A c(15 <br /> Facility Contact: Phone:a0CI 9 Ij a 17 B'S <br /> Date Local Agency Was Notified of Testing: 10 .111Y <br /> Name of Local Agency Inspector(if present during testing): <br /> .,.., <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: WEST STAR ENVIRONMENTAL,INC. O C T 2 1. 2014 <br /> Technician Conduct in Imo, wlelgyws <br /> Credentials': SLB Contractor TCC Service Tech. SWRCB Tank Tester <br /> LicenseNumber(s): -IR r.TAAFUT. <br /> 3elffftRUCKETIESTING INFORMATION <br /> Test Method Used: Hydrostatic Vacuum Other <br /> Test Equipment Used: S7fy1GI Equipment Resolution: t <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number,Stored Product, etc.) <br /> Bucket Installation Type: iree Bury irect u irectB Direct Bury <br /> ontamed in Sum Con coed in Sum in Sum Contained in Sum <br /> Bucket Diameter: tl 1- <br /> -21-Bucket Depth: 131 S <br /> Wait time between applying M tn! �y� �M l rJ <br /> vacuum/watel and start of test: <br /> Test Start Time(Tt): a 3 <br /> Initial Reading(RO: t/ �S <br /> Test End Time(TF): .'�_ AZ;311) �a <br /> Final Reading(Rr): `per a. <br /> Test Duration(TF—Ti): A� <br /> Change in Reading(RF-Rt): 0r!j <br /> Pass/Fail Threshold or <br /> Criteria: Q 5-5 C) . G d S5 C7 W 4e5 <br /> Test Result: Pass Fail Pass Fail Pass Fail Pass Fail <br /> Comments—(include information onrepairs made prior to testing, and recommended o ow-up forfailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the in rmation coni�tted in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: r Date: 0-1 <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 />