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SWRCB,January 2006 <br /> it 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 thejacility ownerloperatorfor submittal to the local regulatory agency, <br /> 1.FACILITY INFORMATION <br /> Facility Name:- <br /> 0ap ----7Date of Testing: <br /> C <br /> Facility Address: e rQ,11 <br /> Facility Contact: L 6V Phone: <br /> Date Local Agency Was Notified of testing. Z <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: FrLyle D.Nimmo El Zane A.Nimmo n David A.Winkler F1 Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': MICC Service Tech. Pj.SWRCB Tank Tester <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Eff-Hydrostatic F1 Vacuum El Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 OD 2 3 4 <br /> Number, Stored Product, et <br /> WDirect Bury El Direct Bury —ffDirect Bury Direct Bury <br /> Bucket Installation Type: ZContained in Sump E4-Contained ❑in Sump n Contained in El Contained in <br /> . Sump Sump <br /> Bucket Diameter: & <br /> Bucket Depth: t e. <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): <br /> Initial Reading(Rj): <br /> Test End Time(TF)- /000 /000 <br /> Final Reading(RF): <br /> Test Duration(TF—TO: <br /> Change in Reading(RF-RI): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: R Pass El Fail aPass El Fait El Fail El Pass El Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> d" <br /> 24-57 L, <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all tb-,t-information iu� 4n tb <br /> is rWort'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 />