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DEC-30-2008 10 :42 AN GETTLER—RYAN INC. 925 551 4770 P. 02 <br /> S WRC B,.lanuary 2006 <br /> Spill Bucket Testing Report Form <br /> ?his form is intended for use by contractors performing annual testing of UST'spill containment structures, The completed form and <br /> prinnmts from tests f fapplicable), should be provided to the facUlry'owner,'operator for submittal ro the local regulatory agemy. <br /> 1, FACILITY INFORMATION _ <br /> Facility Name: — _ Date offesting: <br /> Facility Address: HQ ytp �s tL_�-•.�� � h _�l_ t�S Y_--- <br /> Facility Contact: k6,i „)l <br /> Date Local Agency Was Notified of Testing: t t t.t142X --_ <br /> Name of Local Agency Inspector(ifpresent during testing): Cy�e <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: _..La,r .1LLtrs� _ � ---- -- _— ----- —_ <br /> Technician Conducting Test: _— <br /> Credentials': 6LCSLB Contractor LQCC Tervice Tech. G SWRCB Tank'Tester Other/Specify <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: l drostatic 1.1 Vacuum J Other __ <br /> Test Equipmern Used:— _ t Equipment Resolution: t ' <br /> Identify Spill Bucket (By Tank 1 2 3 4 <br /> Number,Stored Product, etc.) =L�. O t )' <br /> Bucket Installation Type: <br /> gWirect Bury g Direct Bury A.Direct Bury t'.I Direct Bury <br /> C Contained in Summa_ .i Contained in Sumn__ L:Contained in Sum CI Contained in Sump <br /> Bucket Diameter: I.� ('2 ' _ __12 __ Z x 2 <br /> .._A...S.c... <br /> Bucket Depth: <br /> Wait time between applying I <br /> vacuum/water and start of test: .. 1_ <br /> Test Start Time(T,):._ <br /> 2._ — <br /> Initial Reading(Ri): )L. spl�` — tOt' '_—— . ( •��'� _� <br /> Test End Time(TF): <br /> Final Reading(Rr): -- tjV" _ r �/ 1��-�i <br /> Test Duration(TFTJ: Je r — n r _... —_1_I[c r <br /> Change in Reading(RP-Ili): — <br /> Pass/Fail Threshold or <br /> Criteria <br /> FiU i!~Yass' 0 FAB ',*JpsN' .t?ll�+ti pial C1 Fein <br /> Comment$— (include information on repairs made prior to testhSEz, and recommended ollow-up forLailed to <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certyy A&all the information contained in this report lr true,accurate, and in JU11 compllanca with legal regairemenl+. <br /> _....- <br /> Date: - l C.•� <br /> Technician's Sigrrelute:_ '"- <br /> --—"�-3 �racwr. ttoweWR 6W requirements <br /> State laws and regubgOns do nor �- <br /> may he more stringeaL <br />