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• 0 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 Name: eloa t Date of Testing: FacilityAddress: / -qt,, C/ 4!E, 1-1,41q,44ErC L1v> Facility Contact: Phone: Phone: 9i4., Zi1-0-201 Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (if present during testing): G,�(� pe 2. TESTING CONTRACTOR INFORMATION Company Name: S Zii/C Technician Conducting Test: i� Credentials': .1 CSLB Contractor JLICC Service Tech. ❑ SWRCB Tank Tester Y Other (Spec) Q v✓ License Number(s): Szasb 5236-772- CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: (st1.a'{ � �+.�.. Date: h3 -0q ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. 3. SPILL BUCKET TESTING INFORMATION Test Method Used: g Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: Equipment Resolution: Identify Spill Bucket (By Tank 1, 2 3 4 Number, Stored Product, etc. (�i�Si~Z Bucket Installation Type: ADirect Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sum Bucket Diameter: 11 '1 Bucket Depth: / Wait time between applying vacuum/water and start of test: —Ho(.14 Test Start Time (Ti): 3 '. O Initial Reading (Ri): f 'rL " Test End Time (TF): 4 Final Reading (RF): 1;12- ;12Test TestDuration (TF — Ti): Change in Reading (RF - Ri): $ " Pass/Fail Threshold or �5 Criteria: Comments — (include. (include. information, on repairs made prior to testing and recommended follow-up far failed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: (st1.a'{ � �+.�.. Date: h3 -0q ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.