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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 LIST spill containment structures. The completed form and <br />printouts from tests (rf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: p r �e f &e y.- r Date of Testing:& --- 'Z - — Q <br />Facility Address: '7 j- J -e -- 1,() ot . <br />Facility Contact: 15 W ki <br />Phone: <br />Date Local Agency Was Notified of Testing: L — 7- -�t- _a <br />Name of Local Agency Inspector (f present during testing): ,:�,. <br />. V <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 nd 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 />tl Credentials': ,KICC Service Tech. ❑ SWRCB Tank Tester 11 <br />3- SPI'Ll, RUC'KET TESTING INFORMATION <br />Test Method Used: R Hydrostatic ❑ vacuum ❑ Other <br />Test Equipment Used: C,�` -p <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 / <br />2 <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 />El Contained in <br />Sump <br />El Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test: <br />d <br />Test Start Time (Tj): <br />Initial Reading (Rj): <br />1-- r <br />Test End Time (TF): <br />Final Reading (RF): <br />/-5/ <br />Test Duration (TF — TI): <br />h I-- <br />Change in Reading (RF - RI):- <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />0 Pass ❑ Fail <br />[9 Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — <br />//�r-,jL <br />on repairs made prior to testing, and recommended <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />_I hereby certify that all th�fo mation con ed in this report is true, accurate, and in full compliance with legal requirements. <br />_ i r»„ <br />Technician's Signature:7- Date: L� �°` <br />1 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 />