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SWRCB, January 2006 <br />Pill Bucket Westing Report <br />®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 (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: / p <br />Facility Address: s o <br />Facility Contact: Phone. 13 <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 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 ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': CC Service Tech. jaSWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: jS.Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: PIWEquipment <br />Resolution: 1� <br />Identify Spill Bucket (By Tank 1 <br />Number, Stored Product, etc) <br />m.� <br />2 <br />j <br />3 <br />" 6 <br />4 <br />Direct Bury <br />Bucket Installation Type: <br />❑Contained in Sump <br />irect Bury <br />❑Contained in Sump <br />®-Direct Bury <br />❑ Contained in <br />Sump <br />❑ Direct Bury <br />El Contained in <br />Sum <br />Bucket Diameter: <br />Bucket Depth: �Y <br />®�e- <br />r <br />Wait time between applying <br />vacuum/water and start of test:` <br />-- <br />Test Start Time (TI): .:35" <br />j <br />: Jr <br />Initial Reading (Rj): /31", <br />/ ,, <br />f 11 <br />Test End Time (TF): 1D 3- <br />1 J 3 <br />1 O <br />Final Reading (RF): 13 , <br />1 <br />1 <br />Test Duration (TF — TI): Me <br />Change in Reading (RF - RI): <br />Pass/Fail Threshold or <br />Criteria: <br />Test `Result,�' ass ;, ❑Fail <br />n ass,:-`-:❑ FaPasS <br />-,❑Fail <br />; ❑ 'Pass „ :❑Fail <br />a.uminunts — unctuae tnjormatton on repairs made prior to testing and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the infoenation contained in this report 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 />