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0 0 <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/operator for submittal to the local regulatory agency. <br />2. TESTING CONTRACTOR 1 I !` <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: X Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: <br />Identify Spill Bucket (By Tank 1-87 2-91 <br />Number, Stored Product, etc. <br />Equipment Resolution: <br />3- Diesel 4 <br />Bucket Installation Type: X Direct Bury <br />❑ Contained in Sump <br />XDirect Bury <br />❑ Contained in Sump <br />X Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: 11" <br />11" <br />11" <br />Bucket Depth: 10 %Z" <br />10 %2" <br />12" <br />Wait time between applying 10 <br />vacuum/water and start of test: <br />10 <br />10 <br />Test Start Time (Tj): 9:00 <br />9:00 <br />9:00 <br />Initial Reading (RI): 9%11 <br />9 7/8" <br />11 ,/Z„ <br />Test End Time (TF): 1-:00 <br />10:00 <br />10:00 <br />Final Reading (RF): 9'/" <br />9 7/8" <br />11 11/2" <br />Test Duration (TF — TI): 1 hr <br />1 hr <br />1 hr <br />Change in Reading (RF - RI): 0 <br />0 <br />0 <br />Pass/Fail Threshold or pass <br />Criteria: <br />pass <br />Pass <br />Test Result: X Pass ❑ Fail <br />X Pass ❑ Fail J. <br />X Pass ❑Fail <br />❑ Pass ❑ Fail <br />OmmenTS — (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: Date: 7 t <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />