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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended far 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 /> 1.FACILITY INFORMATION <br /> FacilityName: 91 1 Date of Testing: - -Q <br /> Facility Address: a orrt ; <br /> Facility Contact: ,lrj jr. Phone: �'7.Q ' - oj'ff/-- <br /> Date Local Agency Was Notified of Testing: f 7- -O <br /> Name of Local Agency Inspector(ifpresent during testing): G <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"`�Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> yle D.Nimmo ElZane A.Nimmo ElDavid A.Winkler ❑ Felix G.Ramirez <br /> Technician Conducting Test: *5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: D ICC Service Tech. SWRCB Tank Tester <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: P Equipment Resolution: <br /> Identify Spill Bucket(By Tank 12 3 4 <br /> Number, Stored Product, etc. C'r h C/- <br /> Ll Direct Bury [3 Direct Bury Direct Bury Direct Bury <br /> Bucket Installation Type: � p ❑Contained in SumpContained in Sum ❑Contained in El Contained in <br /> Sutra Sum <br /> Bucket Diameter: /f <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: $� <br /> Test Start Time(TO: / $ <br /> Initial Reading(R,): <br /> Test End Time(TF): <br /> Final Reading(RF): /1 V <br /> /60 <br /> Test Duration(TF-T,): t-- <br /> Change in Reading(RF-R,): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: Pass ❑Fail YPass ❑Fail ❑ Pass ❑ Fail ❑ Pass ❑Fail <br /> Comments-(include information on repairs maderior to testing, and recommended ollow- or ailed tests) <br /> or ed <br /> CERTIFICATION <br /> � <br /> LL v r <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information e�ontin -'in this report is true,accurate,and in full compliance with legal regnirvmeota. --- - - <br /> Technician's Signature:-�J (/G'rr_Zd Date: fs z� <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 /> 104 <br />