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Spill Bucket Testing Report Form <br />SWRCB, January0 <br />etc' u 7n1q <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 agencJa Tui <br />1. FACILITY INFORMATION <br />Facility Name: YRC Freight #813 <br />Date of Testing: 0 210112 01 8 <br />Facility Address: 1535 E. Pescadero Avenue <br />Facility Contact: Ruben Phone: (913) 344-3644 <br />Date Local Agency Was Notified of Testing: 1/19/2018 <br />Name of Local Agency Inspector (ifpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Confidence UST Services, Inc. <br />Technician Conducting Test: Aaron Perrigo <br />Credentials: X CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />LicenseNumber(s): CSLB# 804904 ICC# 8485827 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: 0 Hydrostatic Cl Vacuum Other <br />Test Equipment Used: Lake Test I Equipment Resolution: 0.0625" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 Soap <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />ODirect Bury <br />[]Contained in Sum <br />E] Direct Bury <br />[]Contained in Sump <br />❑Direct Bury <br />❑Contained in Sum <br />[]Direct Bury <br />❑Contained in Sum <br />Bucket Diameter: <br />13.00" <br />Bucket Depth: <br />21.50" <br />Wait time between applying <br />vacuum/water and start of test: <br />5 min <br />Test Star[ Time (T,): <br />9:00 am <br />Initial Reading (R,): <br />4.50° <br />Test End Time (TF): <br />10:00 am <br />Final Reading (RF): <br />4.50° <br />Test Duration (TF —T,): <br />1 hr <br />Change in Reading (RF - Rj): <br />0.00" <br />Pass/Fail Threshold or <br />Criteria: <br />0.0625" <br />Test Result: <br />❑x Pass []Fail <br />❑ Pass ❑Fail <br />❑ Pass ❑Fail <br />❑ Pass El Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <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: 40- Date: 02/01/2018 <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 />