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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 stru tures. 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: Date of Testing: Z D <br /> Facility Address: -7 15 K1, F7L Do eA1>0 S-C ST a rS 135 ZOZ- <br /> Facility Contact: Phone: 9 q 3 55 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(f present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo M 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: k— z� Equipment Resolution: " <br /> Identify Spill Bucket(By Tank 1 2a j 3 4 <br /> Number, Stored Product, etc.) �7 1 1 � <br /> Direct Bury El Direct Bury ❑ Direct Buryl ❑Direct Bury <br /> Bucket Installation Type: ;9 Contained in Sump Contained in Sump Su Contained ❑Contained in <br /> Sump I Sum <br /> Bucket Diameter: IN - \k - A <br /> Bucket Depth: 1 VS ILA <br /> — I — <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TO: 0 ()ON^ 00 <br /> Initial Reading(Ri): � �A- \\,/Z- I3- <br /> Test End Time(TF): IQ O o 00C3 10 <br /> Final Reading(RF): 0 I /y I\'�� 1,6- <br /> Test <br /> 3-Test Duration(TF—Tj): V\OV�Z, \ �)Cyj(Z, <br /> Change in Reading(RF-Rj): f� <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Resalt: Pass ❑Fail Pass ❑ Fail Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> CERTIFICATION OIE.�-ECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all 4inf7ion ntained in this report is true,accurate,and in full compliancewith legal requirements. <br /> Technician's Signature <br /> Date: d-,eq^,3`1 <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 />