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SWRCB,January 2006 <br /> 1 Bucket Testing sung Repurt 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 owner/operator for submittal to the local regulatory agency. <br /> -4. FACILITY INFORMATION <br /> Facility �;w <br /> Name: Date of Testin <br /> Facility Address: �{��c o ' , a ' nil <br /> g:l2 r !, A <br /> Facility Contact: <br /> Phone: <br /> Datc Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162"d Street Galt, CA 95632 <br /> (209)744-0112 Fax:(209) 744-0116 <br /> Technician Conducting Test: 0 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: Y ; <br /> Equipment Resolution: '/ ,A <br /> Identify Spill Bucket(By Tank 1 — 2 <br /> Number, Stored Product, e1c.) 1 4 <br /> 3 <br /> Bucket Installation Type: ❑ Direct Bury ❑Direct Bury `Direct Bury ❑ Direct Bury <br /> ❑ Contained in Sump ❑ Contained in Sump d'Contained in ❑Contained in <br /> Bucket Diameter: Sum Sum�� ; <br /> Bucket Depth: <br /> Wait time between applying <br /> i°z <br /> vacuum/water and start of test: ,�/� },J X <br /> Test Start Time(Tj): r j <br /> Initial Readmi (Rj): <br /> Test End Time(TF): r2-O <br /> J 'ice i 03o <br /> Final Reading(RF): 12- <br /> 1 Z <br /> Test Duration(TF—TI): 4 2 <br /> ho 111 , 4,11 CJ tA' <br /> Change in Reading(RF-Ra): <br /> Pass/-ail Threshold or <br /> Criteria: <br /> Test Result: Pas ©Fail Passe ❑Fail <br /> t ,.❑ Pas., El Fail, El Pass ❑Fail <br /> Comments—(include inform repairs made prior to testing; and recommended follow-up for failed tests) <br /> T T C�tif1 l l^J`1 i { '' �rw 'Y t✓,t r.._.t'� r- <br /> 6 <br /> CER'T'IFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I he! oy certify that ailthe in ormation contained in this report is true,accurate,and in full compliance with legal requirements. - <br /> Technician's Si ature: <br /> � Date: <br /> _l <br /> State laws and regulationsIdonot currently require testing-to-b performed by a qualified contractor.Howe <br /> may be more stringent. `l ver,local requirements <br />