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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�t I z �U, �13 <br />Company Name: A & J Environmental <br />Technician Conducting Test: Asa Cosby <br />Credentials': X CSLB Contractor ' X ICC Service Tech. 0 SWRCB Tank Tester 0 Other (Specify) <br />License Number(s):653381 525-2300 <br />3. SPELL BUCKET TESTING INFORMATION <br />Test Method Used: X Hydrostatic 0 Vacuum 0 Other <br />Test Equipment Used: I Equipment Resolution: <br />Comments -(include information on repairs made prior to testing, andrecommended follow-up for failed tests) <br />Technician's Signature: <br />Date: 12%- 3 <br />!A <br />1 State laws and regulations do not currently require testing to be per(bAed by a qualified contractor. However, local requirements <br />Identify Spill Bucket (By Tank 1 2 3 <br />Number, Stored Product, etc.) <br />Bucket Installation Type: 0 Direct Bury 0 Direct Bury 0 Direct Bury <br />)kContained in STEp 0 Contained in Sum p 0 Contained in Sum p <br />0 Direct Bury <br />0 Contained in Sump <br />Bucket Diameter: <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test: ;v) <br />Test Start Time (T): 01760 <br />Initial Reading (RI): <br />Test End Time (TF): Mcu <br />Final Reading (RF): <br />Test Duration (TF - TI): <br />Change in Reading (RF - RI): <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result. Pass 0 Fail 0 Pass 0 Fail 0 Pass 0 Fafl:j <br />0 Pass EFad <br />Comments -(include information on repairs made prior to testing, andrecommended follow-up for failed tests) <br />Technician's Signature: <br />Date: 12%- 3 <br />!A <br />1 State laws and regulations do not currently require testing to be per(bAed by a qualified contractor. However, local requirements <br />