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AUG 1W�' January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill containment strcturr. ~ ;!ompleted form 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: (Y\ Date of Testing: - Zai - / G <br />Facility Address: ?_SC> J g cClGstx- <br />FacilityContact: C L Phone: Zls�� <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (ifpresent during testing) <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name L.C.SERVICES <br />Technician Conducting Test: GABRIEL VENEGAS <br />Credentials': ❑ CSLB Contractor x ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): <br />3. SPILL, BUCKET TESTING INFORMATION <br />Test Method Used: X-- Hydrostatic 11 Vacuum ❑ Other <br />Test Equipment Used:WATER Equipment Resolution:TAP <br />Identify Spill Bucket (By Tank 1 0r) 2 �) 3 �S�-. <br />e. U <br />Number, Stored Product,tc <br />4 <br />Bucket Installation Type: <br />Direct Bury �irect Bury Direct Bury <br />❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br />D Direct Bury <br />D Contained in Sum <br />Bucket Diameter: <br />a l <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test:' <br />i h <br />Test Start Time (Ti): <br />A v, AT^ J <br />Initial Reading (Ri): <br />3-5/(,/ V'/ 3 G <br />Test End Time (TF): <br />C3Afy-11 Qy, <br />Final Reading (RF): <br />Test Duration (TF — Tj): <br />Change in Reading (RF -Rj): <br />Pass/Fail Threshold or <br />Criteria: <br />Y) t) <br />'1`esi Result <br />Pass O;:It`ai . ; Y'ass .,.;L Fg€1 Pass .:' Ci Fail {; <br />3?ass . Ci Fal <br />Comments — (include information on repairs made prior to testing, and recommen ed 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: <br />Date: <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />