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SWRCB,January 200E <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 farm 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 /> Facility Name: Date of Testing: <br /> Facility Address: LL)" 6f4 ; <br /> Facility Contact: Rick,j Pho e: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(fpresent during testing): b C- <br /> 2. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: U.S.T.Compliance Testing Inc. <br /> Technician Conducting Test: Tony Fontana <br /> Credentials': x CSLB Contractor x ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 846288 1064273-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: x Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used:-lf�TB T ,4 Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2Q t 3Dulf4C� 4 <br /> Number, Stored Product, etc) 4?1 <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> J'Contained in Sump YContained in Sump OeContained in Sump ❑Contained in Sum <br /> Bucket Diameter: Q% 2 W <br /> Bucket Depth: N <br /> Wait time between applying <br /> vacuum/water and start of test: ® 8 <br /> Test Start Time(TI): G1jJ <br /> Initial Reading(R): Col <br /> Test End Time(TF): 1003 <br /> Final Reading(RF): 1b .0 <br /> Test Duration(TF-TO: L <br /> Change in Reading(RF-RO: -D <br /> Pass/Fail Threshold or -U -0 0 <br /> Criteria: <br /> Test Result: ,10 Pass []Fail g Pass ❑Fail Pass ❑Fail ❑ Pass ❑Fail <br /> COMMents-(include information on repairs made prior to testing, and recommended follow-up for failed tests), <br /> MAR x(116 <br /> -,NvisomAENTAL <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.- <br /> State <br /> ignature:State laws and regulations do not current y require testing to be performed by a qualified contractor.However, local requirements <br /> may be more stringent. <br />