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.,r ..i <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 containment structures. The completed form and <br /> printouts from tests(if applicable), should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:VZB-LDIKCA Date of Testing: 4125/12 <br /> Facility Address: 2500 West Turner Rd. <br /> Facility Contact:Jonathan Pakele Phone:91.6-439-6042 <br /> Date Local Agency Was Notified of Testing: 48 Hours Prior <br /> Name of Local Agency Inspector(if present during testing): None <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Sunwest Engineering Inc. <br /> Technician Conducting Test: Paul McLane <br /> Credentials : CSLB Contractor[] ICC Service Tech-Z) SWRCB Tank Testero Other(Specify) <br /> License Number(s): 5238651-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Standard Lake Test <br /> Test Equipment Used: None <br /> Identify Spill Bucket(by Tank 1 Diesel Fill 2 3 4 <br /> Number,.Stored Product, etc. <br /> Bucket Installation T Direct Bucy Direct Bury Direct Bury Direct Bury <br /> YPe ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" <br /> Bucket Depth: 14" <br /> Wait time between applying 15 MIN, <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 9:15 AM <br /> Initial Reading(RI): 12.5" <br /> Test End Time(TF): 10:15 AM <br /> Final Reading(Rj): <br /> Test Duration(TF-Tj): I Hour - - - <br /> Change in Reading(RF-Rj): 0" <br /> Pass/Fail Threshold or 0" <br /> Criteria: <br /> VA <br /> .,.y r mss;- �I: '� - <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 <br /> contained in this report is true,accurate,and in full compliance»•Ith legal requirements. <br /> Technician's Signature: /.,O� <br /> Date:4/25/12 <br /> e 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 />