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Spill Bucket Testing Report Form SWRCB,January 2006 <br /> This form is intendedfor 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 /> Facility Name: -T a sto o Date of Testing: I - t 2-O <br /> Facility Address: p g w S c Gd <br /> Facility Contact: Phone: -41 - 1 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2vd 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. © S WRCB Tank Tester <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: q Equipment Resolution: ` i w-- <br /> Identify <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) 9I 3 <br /> Bucket Installation Type: © Direct Bury ©Direct Bury LXJ Direct Bury 0 Direct Bury <br /> ❑Contained in Sump ❑ Contained in Sump ❑ Contained in ❑Contained in <br /> Sump Sum <br /> Bucket Diameter. I t it t t { 1 <br /> Bucket Depth: <br /> l (-z.- <br /> Wait <br /> zWait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T,): a t o R l 0 9 0 ca <br /> Initial Reading(RI): t 1A . a 3 3� <br /> Test End Time(TF): [76 o c o <br /> (010Tb 00 <br /> Final Reading(RF): I ' v 1 1 3I e, 3 3 <br /> Test Duration(TF-TO: Or— <br /> Change in Reading(RF-R): - -4@6— <br /> Pass/Fail Thteshold or <br /> Criteria: <br /> Test Result: Pass ❑Fail Pass ❑Fail Pass ❑Fail Pass ;[]Fail <br /> Comments-(include information on repairs made prior to testing and recommended ollow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all Ve information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signatu Date: t—/z—,07 <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 />