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SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency_ 1. FACILITY INFORMATION Facility NameI Date of Testing: C _ — Facility Address: Cif1 Facility Contact: 7 l l hone: Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (fpresent during testing): u 2. TESTING CONTRACTOR INFORMATION Company Name: U.S.T. Compliance Testing Inc. Technician Conducting Test: Tony Fontana Credentials': x CSLB Contractor x ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) License Number(s): 846288 1064273 -UT z enrr I UlTd"WIVT'rFRTiN(-- 1NVnRMATION x Hydrostatic ❑ Vacuum ❑ Other pUsed: ent Use . TF.S�� Equipment Resolution: ll Bucket (By Tank 1 �� 2 Ct ` 3 \ U 4 Number, Stored Product, etc. fq'Direct Bury &!Direct Bury Direct Bury ❑ Direct Bury Bucket Installation Type: ❑ Contained in Sum ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sum Bucket Diameter: t ' ' `r, ' Bucket Depth: 1 " � }� rl 14 Wait time between applying E3 vacuum/water and start of test: Test Start Time (T,): S, Initial Reading (RI): `%-{ Test End Time (TF): Final Reading (RF): l Test Duration (TF— Ti): hlL2 Change in Reading (RF - R): Pass/Fail Threshold or ^ b -0 Criteria: B' Pass ❑Fail Pass ❑Fail ❑Pass El Fail Test Result' 9 Pass ❑ Fail Comments — (include information on repairs made prior to testing, urnu CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING hereby certify that all the information contained in this report is true, accurate, and in full compliance wills legal requirements. Date:_ eJ' `— r -S Technician's Signature: ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.