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a. *.W <br /> 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(ifapplicable),should be provided to thefacility owner/operator for submittal to the 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 panpi <br /> Facility Contact: TED Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(tfpresent during testing): ELANA �LB 14 7017 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 tad Street Galt,CA 95632 (209)744701 ULFpARME*-V116 <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: 1116 <br /> Identify Spill Bucket(By Tank 1 87 2 DSL 3 91 <br /> Number, Stored Product, etc) <br /> Direct Bu ❑ Direct Bury <br /> E:1 '7' ❑Direct Bury Su Contained in <br /> Bucket Installation Type: <br /> ® Contained in Sump ®Contained in Sump Sum <br /> Bucket Diameter: 1 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(Ru): 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—Tj): IHR 114R IHR <br /> Change in Reading(RF-Rt): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑ Fait ® 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 /> 1 hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements.�� <br /> Technician's Signature: Date: 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 />