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0 10 RECEIVEL <br />SWR?, J ary 2006 <br />Spill Bucket Testing Report Form JAN 1 21 <br />This form is intended for use by contractors performing annual testing of UST spill containment str . nd <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal t 'r004 <br />I- FACILITY INFORMATION <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 ❑ Zane A. Nimmo ❑ David A. Winkler E Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />I Credentials': E ICC Service Tech. E SWRCB Tank Tester <br />2 QDTT T RTTr1Wr'r r QTTN('-' TNMUM®TInN <br />Test Method Used: E Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank 1 87 2 91 3 DIE 4 <br />Number, Stored Product, etc. <br />Bucket Installation Type: <br />❑ Direct Bury <br />E Contained in Sump <br />Direct Bury <br />E] Direct Bury E]E Contained in <br />E Contained in Sump Sump <br />F-1DirectBury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 11 <br />Bucket Depth: <br />13 <br />13 13 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />_ - <br />Test Start Time (Ti): <br />918 <br />918 918 <br />Initial Reading (Rj): <br />13 <br />13 13 <br />Test End Time (TF): <br />1018 <br />1018 1018 <br />Final Reading (RF): <br />13 <br />13 13 <br />Test Duration (TF — TI): <br />1 HOUR <br />1 HOUR 1 HOUR <br />Change in Reading (RF - RI): <br />0 <br />0 0 <br />Pass/Fail Threshold or <br />Criteria: <br />_ <br />Test Result: <br />E Pass ❑ Fail <br />E ;Pass El Fail I E Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up jor jailed tests) <br />PHIL TITS BUCKETS <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING 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: Date:01-14-15 <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 />