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SWRCB, January 2006 <br />Spill Bucket Testing Report FG..n <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_ FACII.YrV WFORMA'1'I(- N <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 1(209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo @N David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': ❑ ICC Service Tech. IN SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: <br />j <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 <br />2�,/ <br />3 of <br />4 <br />Bucket Installation Type: <br />© Direct Bury <br />E]Contained in Sump <br />® Direct Bury® <br />ElContained in Sump <br />Direct Bury <br />❑ Contained in <br />Swnp <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />t L <br />Bucket Depth: <br />3 <br />t `i <br />�y y <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />J`f yv <br />I b() <br />�Y V <br />Initial Reading (Rj): <br />Q Y lr <br />10 <br />/J y <br />Test End Time (TF): <br />i <br />V- 1'700 <br />S y s <br />Final Reading (RF): <br />Q Z, <br />0 <br />0 y <br />Test Duration (TF — Tj): <br />l <br />/ <br />Change in Reading (RF - Rj): <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />ass ❑ Fail <br />[a Pass ❑ Fail <br />I „O—Pass ❑ Fail <br />❑ Vass, ❑ Fail <br />CERTIFICATION OFT HNIC RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the in rm-ation cont ined in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: 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 />