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Spill Bucket Testing Report F'! m <br />SWi�CB, January 2006 <br />This form is intended for use by contractors performing annual testing of LIST 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. FACI3.ITV INFORMATMN <br />Facility Name: �'j1� ✓ y _ _ s Date of Testing: _ <br />Facility Address: <br />Facility Contact: Phon .207 73:5 -,:5 03 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector. (fpresent 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: El Lyle D. Nimmo El Zane A. Nimmo David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />I Credentials': BICC Service Tech. ,J!9-SWRCB Tank Tester <br />3. SPHL BUCKET TESTING1 ORO, <br />i est Memoa usea: tSl Hydrostatic L j Vacuum ❑ Other <br />Test Equipment Used: T -,g . 0 <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank 1 © <br />Number, Stored Product, etc. !J 7� �-fi� / <br />2 <br />�j "lbs <br />3 <br />4 <br />❑ Direct Bury <br />Bucket Installation Type: (_Contained in Sump21-Contained <br />El Direct Bury <br />in Sump <br />❑ Direct Bury <br />Q Contained in <br />Sump <br />F] Direct Bury <br />® Contained in <br />Sum <br />Bucket Diameter: <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test:. <br />- <br />Test Start Time (Tj): •. <br />pp <br />2-; ® v <br />Z ' OCD <br />Initial Reading (RI): <br />Test End Time (TF): <br />t 00 <br />Final Reading (RF): <br />Test Duration (TF - Tj): <br />ZiZ� <br />Change in Reading (RF - RI): <br />Pass/Fail Threshold or <br />Criteria: <br />Ee�s=tesult: ❑ Pass - KFail <br />^---- - <br />Pass ❑Fail <br />L�Pass ; ❑Fail <br />[� Pass ❑ Fail <br />`-arra®enzs - (include information on repairs made prior to testing and recommended follow-up for failed tests) <br />rA 6i.S T/� tr / rC�+'S'� / LL �' c J G� cT T{iQJ- `y' ° ,�,q i L F l ��p►./.�// aiCo%�,�/ <br />/�-V ,S ! /�►r� ,7L—���,e .,i , �"�J� / /'a ! C?� C `.. �. nes'c-4 <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all tji06rma ' conted in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: Date: --7-- / as <br />' State laws and regulations do not currently equ' et—mgt erformed b a qualified contractor. However, local requirements <br />may be more stringent. <br />