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1 <br /> SWRCB,January 2006 <br /> ` Stl Bucket Testing a ®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: 11 $ A, Date of Testing: — .a 6) <br /> Facility Address: ' ! <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector ff present during testing): M j clvo < <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2°d Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ❑ Zane A.Nimmo XDavid A. Winkler ❑ Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: ❑ ICC Service Tech. SWRCB Tank Tester i;7S <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: -E�`gydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc. <br /> OW <br /> ❑ Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: arced in Sum F] Contained in ❑Contained in <br /> [--�-Ge�rt � p El in Sump Sump Sum <br /> Bucket Diameter: <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): <br /> Initial Reading(Rj): 1 <br /> Test End Time(TF): <br /> Final Reading(RF): ' <br /> Test Duration(TF—Tj): <br /> Change in Reading(RF-RI): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: Pa s ❑Fail ❑ Pass ❑Fail ❑ Pass <br /> El Fail El Pass ❑Fail <br /> Comments—(include inform ion on re airs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECH ICIAN RESPON IBLE FOR CONDUCTING THIS TESTING <br /> I here -certify that all the informati n contained' i report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature:� Date: <br /> State laws and regulations do not c rrently require testing to be performed by a qualified contractor.However, local requirements <br /> may be more stringent. <br />