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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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: -r a -g Date of Testing: 1 - 12 p <br /> Facility Address: g <br /> Facility Contact: phone: <br /> Date 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 416 2'Street Galt,CA 95632 (209)744-0112 Far:(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. Q S WRCB Tank Tester <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum T70ther <br /> Test Equipment Used: q lv* z0 Equipment Resolution: ' 1 t. <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) 07 011 <br /> Bucket Installation Type: © Direct Bury ©Direct Bury Z Direct Bury Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in ❑ Contained in <br /> Sump Sum <br /> Bucket Diameter. I I 1 1 I I + I <br /> Bucket Depth: t Z -z- <br /> Wait <br /> Wait time between applying ` <br /> vacuum/water and start of test: <br /> Test Start Time(T1): c l V R 10 9 o ca <br /> Initial Reading(RO: I l l 3 3 3/ <br /> Test End Time(TF): co 0 0 o a <br /> Iola IO ob <br /> Final Reading(RF): I ' Y 1 S/4 U -5 3 <br /> Test Duration(TF-T�: <br /> Change in Reading(RF-R,): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: Pass E]tail Pass `-❑Fail Pass `❑Fail Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommendedfollow-up or failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS T .ST NG - <br /> I hereby certify that all the information contained in this report is true,acwrate,and in full compliance with legal requirements. <br /> Technician's Signa Date:- <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 />