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RE=-:-CMYEDD 110) (P <br /> SEP 0 8 2008 <br /> SWRC8,January 2006 <br /> ENVIRONMENT HEALTH Spill Bucket Testing Report Form <br /> pE TjaEAj) je4for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts f:•om tests(if applicable), should be provided to thelatility owner/operator fo; submittal to the local regulatory agency. <br /> 1.FACILITY IMI+ORMATION <br /> Facility Name: >/,�, l` Date of Testing: - _ <br /> Facility Address: e j.•<' , - 4 r "rt/ <br /> Facility Contact: j F.�.� Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> r <br /> 2.TESTING CONTRACTOR INFORIAATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A. Winkler [3 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: j Equipment Resolution: <br /> _. <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) ! �,� �-`� <br /> Bucket Installation Type: ❑ Direct Bury Direct Bury 0"Direct Bury ❑ Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump 0 Contained in ❑Contained in <br /> Sum Sum <br /> Bucket Diameter: % 1 f <br /> Bucket Depth: > <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T�): <br /> Initial Reading(RI): <br /> Test End Time(TF): <br /> Final Reading(RF): <br /> f� <br /> Test Duration(TF—TO: <br /> Change in Reading(RF-Rl): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: Pass ❑ FailPass ❑Fail ❑.Dass El Fail E] Pass El Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-u for failed tests) <br /> W. <br /> CERTIFICATION OF TE901CIAN RESPONSIBLE FOR C1ND THIS TESTING <br /> I hereby certify that all tAifor tion containeddiin this• eport is 06ee,,acc ate,and i full compliance with legal requirements. <br /> Technician's Signature: � Date:� State laws and regulatnot currently require t tag to be performed a qualified contractor.However,local requirements <br /> may be more stringent. . <br /> SJ L <br />