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SWRCB, January 2006 <br />Spill 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 Born tests (if applicable), should beprovided to the facility ownerloperatorfor submittal to the local regulatory agency. <br />Facility Name: <br />a-ri.j.ran 777Tate7o fTesting: <br />Facility Address: e\ Lox/\ 0, o r) <br />Facility Contact: Phone: <br />Date Local Agency A7gency Was 7Not7ified Foffestmig :77 <br />FName of Local Agency Inspector. (i(present during testing): <br />2. TESTING rnNTR A VTn-V YMWnM A -rYnXT <br />N AF nd <br />Company Name: AFFORDIA TEST 416 2 Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Company <br />Conducting Test: : Ej Lyle D. Nimmo F] Zane A. Nimmo 91 David -A. Winkler EA Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': El ICC Service Tech. V SWRCB Tank Tester CV- I In <br />A Q.V11r I IDITA-11WIV nrv-onoy�Ts �x_, - - __- <br />Test Method Used: NPHydrostatic El vacuum ❑—Other <br />Test t - Equ , ipme nt - U -1 sed: <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank J77 <br />Number, Stored Product, etc. <br />2 <br />3 <br />4 <br />Bucket Installation Type: El Direct Bury <br />Contained in Sump <br />❑ Direct Bury <br />❑Contained in Sump <br />❑E] Direct Bury <br />F1 Contained in <br />Sump <br />Tect Bury <br />F1 Contained in <br />Sump <br />Bucket Diameter: <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (T1) - <br />Initial Reading (R,): <br />Test End Time (TF): 3 <br />Final Reading (RF): /0 <br />Test Duration (TF -TO: A/ <br />Change in Reading (RF - RI): <br />Pass/Fail Threshold br <br />Criteria: <br />LTest Result: NPass EI,Fail <br />El Pass -1 Fail <br />F] Pass El Fail <br />[11:�Pa:S:S::JD AFail <br />(Irlwuue lryurmallon on repairs Maae prior to testing, and recommended follow-upfor failed tests) <br />CERTIFICATION OF TECHNICIAN RE PONSIBLE FOR CONDUCTING THIS TESTING <br />co�naine, <br />.1-ii-ereby certify that all the informajti;6 containe 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 />