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• 0 <br /> SWRCE3,.lamcary 2006 <br /> Spill Bucket Vesting 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(tf applicable),should be provided to the facility ownerfoperator for submittal to the local regulatory agency. <br /> 1,FACILITY INFORMATION <br /> FacilityName: v J�t t4 f Date of Testing: — Z <br /> Facility Address: hvi K— <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(tf present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2°"Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: CA Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': �]4 ICC Service Tech. SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: �/ 1✓ . :2 Equipment Resolution: /: > " <br /> Identify Spill Bucket(By Tank 1 2 l 3 4 <br /> Number, Stored Product, etc. q t ' `�. i <br /> Direct Bury 13 Direct Bury <br /> ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: Contained in Sump ❑ Contained in Sump ❑ 'Contained in ❑ Contained in i <br /> Sump Sum <br /> Bucket Diameter: <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T[): C1 4 5 <9 9 5) <br /> Initial Reading(R[): <br /> Test End Time(TF): S t'ti <br /> Final Reading(RF): :ZVI <br /> Test Duration(TF—T[): vp,j(- <br /> Change in Reading(RF-R[): l <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: Pass ❑Fail "'' Pass [] Fail Pass ❑ Faii ❑ Pass <br /> ❑ Fail <br /> Comments--(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certify than a 1 the inf ' n contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date:—;Z, .✓p <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 />