Laserfiche WebLink
y 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 INFORMA'I UN <br /> I[Fac'""YName: 1 1 Date of Testing:ity Address: 3�"1 $ . L�✓ Lac , t.A <br /> Facility Contact: ., i ' Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> _ 2. TESTING CONTRACTOR INFORMATION <br /> F <br /> pany Namc: 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 /> Credentials: El ICC Service Tech. `SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Nniydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: ,JVArJ ,,,1'40— I Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) �� ./j/1 Y, .." h OS L <br /> ®Direct Bury ® Direct Bury ® Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ❑ Contained in El Contained in Sump El Contained in Sump Contained in <br /> Sump Sum <br /> Bucket Diameter: Z Z <br /> Bucket Depth: ( Z_ <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): C.� L 5_0 <br /> Initial Reading(114): <br /> Test End Time(TF): �f`,�� Wil} <br /> Final Reading(RF): %/ <br /> Test Duration(TF—Ti): I`j / <br /> Change in Reading(RF-Rj): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: /Pass ❑ Fail ass ❑Fail Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TEC NICIAN RES NSIBLE FOR(CONDUCTING THIS TESTING <br /> I hewiy certify that all the infor ation contained in is report is tr e,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: <br /> L_ <br /> State laws and regulations do t currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />