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SWRCB,January 2006 <br /> Spill Bucket ,resting 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 o3wnerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: _J `'x _ Date of Testing:J'A p1 , Q U <br /> Facility Address: 'a j. 11 r C TM. `< -D <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notifie2l of Testing: 13 112-!c '-1 <br /> Name of Local Agency Inspector(rfpresent during testing) ` - t,` TD joYe <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A. Winkler Z. Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': Z ICC Service Tech. .Q S WRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑ Vacuum 0 Other <br /> Test Equipment Used: Equipment Resolution: ` <br /> Identify Spill Bucket(By 'frank 1 2 1 4 _ <br /> Number, Stored Product, etc. <br /> 0 Direct Bury Direct Bury ❑® Direct Bury Direct Bury <br /> Bucket Installation Type: ❑Contained in 0 Contained in <br /> ❑ Contained in Sump Q Contained in Sump Sump Sum <br /> Bucket Diameter: j <br /> Bucket Depth: #testt: <br /> Wait time between a <br /> vacuum/water and stTest Start Time(T�); p <br /> Initial Reading(Rj): 1 2 17 ) 2- <br /> Test <br /> ZTest End Time(TF): '�?��� '3 <br /> Final Reading(RF): '-, <br /> Test Duration(Tr—T' 1): I h r Vl U t` { <br /> Change in Reading(RF-Rj): <br /> Pass/.Fail Threshold or <br /> Criteria: _ <br /> Test Result; Pass Q Fail - Pass Q Fail Pas ❑ Fail Q Pass <br /> [] Fail <br /> Comments—(include in ormat oi7z�i repairs madeprior totestin , and recanmen o low-u or failed tests - �- <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the in r tion,eontame in this report-w'trueaaccurate,and in fall compliance with legal requirements.. <br /> Technician's Signature: Date; U _L <br /> ' State laws and regulati n do not urrentl}llrequire test' to be performed by a qualified contractor. However, local requirements <br /> may be more stringent r' <br />