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L-1 <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 ownerloperatorfor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Date of Testing: <br />Facility Address: tow <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: 19 <br />Technician Conducting Test: <br />Credentials' : 11 CSLB Contractor 14CC Service Tech. 0 SWRC13 Tank Tester El Other (Specify) <br />License Number(s): C 2 �/j q q 2 <br />Test Method Used: — - - <br />- ;.?Hydrostatic <br />0 Vacuum <br />0 Other <br />Test Equipment Used: 6R L4 <br />Identify Spill Bucket (Bv Tank <br />Number, Stored Product, etc.) <br />Bucket Installation Type: <br />Lv-c <br />1 <br />Wdirect Bun <br />0 Contained in Suns p <br />2 <br />irect Bun. <br />0 Contained in Sump <br />Equipment Resolution: <br />3 4 <br />016irect Bun- 0 Pirect Bum <br />0 Contained in Sump 11 Contained in Sump <br />Bucket Diameter: <br />`r <br />Bucket Depth: <br />j Z <br />Wait time between applying <br />vacuunilivater and start of test: <br />o <br />jj> ti K <br />I Of Soft. sk <br />*A <br />Test Start Time (Tj): <br />Initial Reading (Rj): <br />Test End Time (TF): <br />Final Reading (RF): <br />10 <br />to It <br />Test Duration (TF - TI): <br />Change in Reading (RF - Rj): <br />Pass/Fail Threshold or <br />Criteriti. <br />j <br />Test Result: <br />YPuss 0 Fail <br />WPass 0 Fail <br />Pass 0 Fail 0 Pass 0 Fail <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 hereAv certify that all the information contained in this report is true, accurate, and in full compliance with legal requirenwnt& <br />Technician's Signature: li�( Date: <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />M,317 ho mnn- ctrinas."I <br />