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Npill Bucket Testing Report Form SWRCB, January 2006 <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 INFORM- <br />Facility Name: i �yO F : - - <br />Facility Address: 12j <br />Facility Contact: <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (rf present during testing): - <br />Phone: <br />Date of Testing:, '�F.,t • $ yrs Y <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2"d Street Galt, CA 95632 <br />(209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ❑ David A. Winkler V Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': [ CC Service Tech. `E SWRCB Tank Tester <br />Bucket Diameter: <br />3. SPILL BUCKET TESTING INFORMATION <br />Test ivieihod Used: <br />❑Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: <br />' �� <br />Equipment Resolution <br />Identify Spill Bucket (By Tank <br />Number, Stored <br />2 <br />1030 <br />3 - <br />4 <br />Product, etc.) <br />,•„r,•' <br />Test End Time (TF): <br />s <br />Bucket Installation Type: <br />' <br />❑ Direct Bury <br />in Sumpontained <br />❑ Direct B <br />Bury <br />in Sum p <br />❑ Direct Bury ❑ Direct B <br />uryontained <br />ontained in El Contained in <br />0--- <br />Bucket Diameter: <br />; 1 <br />l ! ' <br />j Bucket Depth: <br />I <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />1030 <br />ICO O <br />Initial Reading (R): <br />! <br />l <br />Test End Time (TF): <br />a -3 D <br />O <br />Final Reading (RF): <br />4 `� <br />, <br />! z <br />Test Duration (TF — T1): <br />viouf <br />Change in Reading (RF - RI): <br />Pass/Fail Threshold or <br />Criteria: <br />- <br />r -- <br />Test Result: <br />Pa ❑ Fail <br />ass ❑ Fail <br />Comments — (include inform <br />ton on airs made Prior <br />to testy g, and recommen, <br />r(7uY"Y) oto <br />I /Z i <br />�� � '�ix.�yY <br />CERTIFICATION OF <br />I hereby certify that all the in <br />Technician's Signature: / <br />' State laws and regulations <br />may be more stringeL----/ <br />❑ Pass <br />led folio -u <br />-�; <br />❑ Pass [:]Fail <br />gists) <br />;CHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING 5 <br />enation contained in this report istr,��accurate, and in full compliance with legal requirertohts. <br />Date: Uj /Z J <br />not currently require testing to be performed by a qualified contractor. However, local requirements <br />