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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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: e -e f do h r Date of Testing: p <br />Facility Address: -7 6 / E: t" LC) u <br />Facility Contact: S Phone: <br />Date Local Agency Was Notified of Testing: 4-7-2--01 <br />p p� <br />Name of Local Agency Inspector (if present during testing): �% K <br />2. TESTING CONTRACTOR IlNFORMATION <br />Company Name: AFFORDA TEST 4162 d Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: R ILyle D. Nimmo ❑ Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />I Credentials': ,[MCC Service Tech. ❑ SWRCB Tank Tester N <br />3_ SPTT.T, RTTCWF.T TF,STTNr INFORMATION <br />Test Method Used: Hydrostatic ❑ vacuum ❑ Other <br />Test Equipment Used: <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 <br />2 , <br />u <br />3 <br />4 <br />Bucket Installation Type: <br />,Direct Bury <br />❑ Contained in Sump <br />Direct Bury <br />Contained in Sump <br />❑Direct Bury <br />❑ Contained in <br />Sump <br />Direct Bury � <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />-77- <br />Bucket Depth: <br />/ �-- <br />Wait time between applying <br />vacuum/water and start of test: <br />d <br />d <br />Test Start Time (Ti): <br />Initial Reading (RI):�-- <br />F <br />Test End Time (TF): <br />Final Reading (RF): <br />/,c� r' <br />/ �✓ `" <br />Test Duration (TF — TI): <br />Change in Reading (RF - Rj):---- <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />0 Pass ❑ Fail <br />M Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended fallow -up for failed tests) <br />R <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all th * fo mation con"ed ed in this report is true, accurate, and in full compliance with legal requirements. �} <br />Technician's Signature:- Date: L� <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 />