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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 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 />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2°d 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': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: H2O TAPE MEASURE <br />Identify Spill Bucket (By Tank 1 87 OCT 2 91 OCT <br />Number, Stored Product, etc) <br />Type: ❑Direct Bury ❑Direct Bury <br />Bucket Installation T yp ® Contained in Sump ® Contained in Stump <br />Equipment Resolution: <br />3 DSL <br />1:1 Direct Bury <br />® Contained in <br />Sump <br />4 NA <br />❑Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />I 1 <br />11 <br />Bucket Depth: <br />12 <br />14.50 <br />11.50 <br />Wait time between applying <br />vacuum/water and start of test: <br />NA <br />NA <br />NA <br />Test Start Time (Tj): <br />900 <br />900 <br />900 <br />Initial Reading (Ri): <br />I <br />11 <br />13 <br />10 <br />Test End Time (TF): <br />1000 <br />1000 <br />1000 <br />Final Reading (RF): <br />11 <br />13 <br />10 <br />Test Duration (TF — Ti): <br />IHR <br />IHR <br />IHR <br />Change in Reading (RF - R3): <br />0 <br />0 <br />O <br />Pass/Fail Threshold or <br />Criteria: <br />NA <br />NA <br />NA <br />Test Result: <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />❑ Pass ❑ Fait <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TE NICIA RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the infor -tion 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 />