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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 />1. FACILITY INFORMATION <br />2. TESTING CONTRACTOR INFORMATION APR 1 7 2018 <br />3. SPILL BUCKET ► •:►t: • <br />Test Method Used: [R]Hydrostatic ❑Vacuum []Other <br />Test Equipment Used: Water <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />1 Tank 1 <br />2 <br />3 4 <br />Bucket Installation Type: <br />❑Direct Bury <br />❑✓ Contained in SM!n2 <br />❑Direct Bury <br />❑Contained in Sump <br />[]Direct Bury []Direct Bury <br />❑Contained in Sump ❑Contained in Sum <br />Bucket Diameter (inches): <br />12" <br />Bucket Depth (inches): <br />12" <br />Wait time (min) between applying <br />vacuum/water and start of test: <br />15 Min <br />Test Start Time (Ti): <br />9:00 <br />Initial Reading (RI): <br />2" Below Grade <br />Test End Time (TF): <br />10:00 <br />Final Reading (RF): <br />2" below grade <br />Test Duration (TF — T1): <br />1 Hr <br />Change in Reading (RF - R1): <br />0.00 <br />Pass/Fail Threshold or <br />Criteria: <br />118" <br />$i <br />Test Res4ite <br />" a� ❑ <br />IC: �3 � �il <br />y� g 7� S <br />❑F 011 <br />M '®R II ❑ $ $3I <br />Comments — (include in ormation on re airs made rior to testing, and recommended allow -u or ailed 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: Kral Kinder ° 1' b'"'�K71de, <br />g Date. 2018.04.1011:07:21.07W <br />Date: 4/18/2018 <br />t 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 />