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3 2017 SWRCB,January 2006 <br /> Spill Bucket Testing Report Form T <br /> This farm is intended for use by contractors performing annual testing of UST sp±{(��ntainment structures. Th�oTileted form and <br /> printouts from tests(if applicable), should be provided to the facility owner/ope�irfvrbt submilt_ititV,he local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: VDP CFN I Date of Testing: 1-31-2017 <br /> Facility Address: 816 S FRONTAGE RD RIPON CA 95336 <br /> Facility Contact: TED Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): ELANA <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: ❑Lyle D.Nimmo ❑ Zane A.Nimmo ® David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ®ICC Service Tech. ®SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br /> MENOMONEE— <br /> Identify Spill Bucket(By Tank 1 87 2 DSL 3 91 <br /> Number,Stored Product, etc. <br /> ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ®Contained in <br /> ®Contained in Sump ®Contained in Sump Sum <br /> Bucket Diameter: I 1 11 11 <br /> Bucket Depth: 12.50 13.50 14.50 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1 1 1 <br /> Initial Reading(Ri): 12.50 13.50 14.50 <br /> Test End Time(TF): 2 2 2 <br /> Final Reading(RF): 12.50 13.50 14.50 <br /> Test Duration(TF—TI): IHR IHR IHR <br /> Change in Reading(RF-Rt): 0 0 1 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: 1 ® Pass ❑Fail ® Pass ❑ Fail ® Pass ❑ 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 /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: �! — aDate: 1-31-2017 <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 />