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SWRCB,January 2006 <br /> Spill Buckct Testing Deport 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: t jv, , $ Date of Testing: - I,3 - C `), <br /> Facility Address: <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): f� �}- <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nO Street Galt, CA 95632 (209) 744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Lyle D. Nimmo ❑ Zane A. Nimmo 0 David A. Winkler ❑ Felix G.Ramirez <br /> 5249115 5263322 5263373 5273934 <br /> Credentials': ❑ ICC Service Tech. 41 SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®-Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: T,1 10,5 ZO Equipment Resolution: /e s' <br /> Identify Spill Bucket(By Tank 1 2 / 3 4 <br /> Number, Stored Product, etc.) ' <br /> ❑ Direct Bury ❑Direct Bury Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: El Contained in ❑ Contained in <br /> [�Contained in Sump Contained in Sump Sump Sum <br /> Bucket Diameter: <br /> Bucket Depth: 1312- <br /> Wait <br /> 3 ' 2- <br /> Wait time between applying <br /> vacuum/water and start of test: -- <br /> Test Start Time(TI): 4� �S O <br /> Initial Reading(RI): t L <br /> Test End Time(TF): <br /> Final Reading(RF): ii //Z- <br /> Test <br /> ZTest Duration(TF—TI): f /Y Ot <br /> Change in Reading(RF-RI): .4(P -� <br /> Pass/Fail Threshold or <br /> Criteria: ` <br /> Test Result: ass ❑ Fail a Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> & ;S c: 6--t /& r <br /> L6✓1 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CO.DUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: v " r l Date: Z / <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 />