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0 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 />2. TESTING CONTRACTOR INFORMATION <br />Company Name: A & J Environmental <br />Technician Conducting Test: Asa Cosby <br />Credentials': X CSLB Contractor X ICC Service Tech. 0 SVfRCB Tank Tester 0 Other (Specify) <br />License Number(s):653381 525-2300 <br />3. SPHL BUCKET TESTING INFORMATION <br />Test Method Used: X Hydrostatic 0 Vacuum 0 Other <br />Test Equipment Used: <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank 12 <br />Number, Stored Product, etc.4t: ( <br />3 4 <br />Bucket Installation Type: 0 Direct Bury <br />)kContained in Sump <br />0 Direct Bury <br />0 Contained in Sump <br />0 Direct Bury 0 Direct Bury <br />0 Contained in Sump 0 Contained in Sump <br />Bucket Diameter: <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test: Kite) <br />Test Start Time (TI): healor imao <br />Initial Reading (RI): <br />Test End Time (TF): <br />Final Reading (RF): <br />Test Duration (TF — TI): <br />Change in Reading (RF - RI): 149)— <br />Pass/Fail Threshold or <br />Criteria: —41— <br />Test Result: 0 Pass 0 Fail <br />0 Pass 0 Fail <br />0 Pass 0 Fail 0 Pass 0 Fad —j <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />W OMA ki 151 NEI ki I I I <br />Technician's Si <br />1 State laws and regulations do not currently require testing to be pfrtprmed by a qualified contractor. However, local requirements <br />