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SWRCB, January 2006 <br />$11 Bucket Testing Report 1:;'®r <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 (rf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1.1'iAfTY.1TV 1V.WnVMArFnw <br />Facility Name: <br />Date of Testing: <br />Facility Address: A,1,66 1 Iwev-r M CA <br />Facility Contact: Phone: _ 1 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (rf present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo EM'David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials: ❑ ICC Service Tech. W'SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: [RHydrostatic ❑ Vacuum ❑ Other <br />• <br />Test Equipment Used: Al <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank 1 <br />Number, Stored Product, etc.) <br />2 <br />3 <br />4 <br />Bucket Installation Type: Direct Bury ` <br />❑ Contained in Sump <br />�birect Bury <br />❑ Contained in Sump <br />'Direct Bury <br />❑ Contained in <br />Sump <br />❑Direct Bu D' <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />Bucket Depth: 3 `% <br />13 X <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TI): <br />Initial Reading (RI): <br />Test End Time (TF): <br />(� <br />Final Reading (RF) <br />Test Duration (TF – TI): f <br />�� <br />Change in Reading (RF - RI): <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: 21 Pass ❑ Fail <br />Pass ❑Fail <br />Pass ❑Fail <br />= ❑ Pass ,, ❑ Fail <br />%-uminent;s {inc[uae injormatton on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF T ICIAN RES NSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that ,,- th formation c twined this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: l r Date: I "- ) 6 <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 />