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Spill Bucket Report Form SWRCB, January 2006 This form is intended for use by contractors petforming annual testing of UST spill containment structures. The completed for to and printouts front tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatmy agency. 1. FACILITY INFORMATION Name: Confidence , Technician Conducting Test:Bry an A Self Credentials': Z CSLB Contractor 5 ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other License Number(s): 804904 8022804 3. SPILL BUCKET TESTING INFORMATION Comments — (include information on repairs, made prior to Test Method Used: V/ Hydrostatic El Vacuum 0 Other Test Equipment Used: Lake Test Equipment Resolution 0.0625' Identify Spill Bucket (By Tank 1 2 3 4 Super 9l Number, Stored Product, etc. ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury [I Direct Bury Bucket Installation Type: 0 Contained in Sum El Container] in Sum [I Contained in Sum FJ Contained in Sum Bucket Diameter: 12.00" Bucket Depth: 14.00" Wait time between applying 5 Min vacuum/water and start of test: Test Start Time (T►): 1:00 pm Initial Reading (111): 12.25" Test End Time (TF): 2:00 pm Final Reading (RF): 12.25 Test Duration (TF — Ti): 1 Hour Change in Reading (RF - R►): 0.00" Pass/Fail Threshold or 0.0625" Criteria: Test Results41: © Pass ❑ Fail ❑ Pass ❑ Fail ❑Pass ❑Fail ❑Pass ❑Fail testing and recommended follow-up,(ot• faired tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE I hereby certify that all the Technician's Signature:, State laws and regulations do not may be more stringent. contained in this testing to CONDUCTING THIS TESTING and in full compliance with legal requiretnettts. Date: 09/06/2018 by a qualified contractor. However, local requirements UST ServicesInc.