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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 /> Facility Name: Date of Testing: V -ZZ <br /> Facility Address: -7)3 A) C 1'0U✓✓}cAz- GA,+VA) <br /> Facility Contact: jPhone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 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. IN SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 24 <br /> Number,Stored Product, etc.) I k�� r ./ 3 �0-,M:• <br /> ❑ Direct Bury ❑Direct Bury E] Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ®Contained in <br /> ®Contained in Sump ®Contained in Sump El Contained in <br /> Sump Sum <br /> Bucket Diameter: I I <br /> Bucket Depth: 17- <br /> Wait <br /> 7,Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 910 S/o Si v <br /> Initial Reading(Rj): 7— mt)>' y <br /> Test End Time(TF): /OIL) <br /> J U t y J O l J <br /> Final Reading(RF): <br /> Test Duration(TF— <br /> Change in Reading(RF-Rj): y ,ar, <br /> Pass/Fail Threshold or <br /> Criteria: y <br /> Test Result: "1* Pass ❑ Fail M Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments— include information on repairs made prior to testing, and recommended ollow-u for ailed tests) <br /> A r PRs <br /> CERTIFICATION O fCHNICIAN ICES ONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all th information contained i this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: ��� Z J� <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 />