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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 from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 "d Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ® David A. Winkler El Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />N Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 11 <br />A CPTT.T. RTTCKF.T TF.RTTNG INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: H2O TAPE <br />MEASURE <br />1 87 2 91 <br />® Direct Bury ®Direct Bury <br />❑Contained in Sump ❑ Contained in Sump <br />Equipment Resolution: <br />3 DSL <br />®Direct Bury <br />Contained in <br />SumpSum <br />4 <br />F-1 Direct Bury <br />❑ Contained in <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />Bucket Installation Type:F1 <br />Bucket Diameter: <br />11 11 <br />11 <br />Bucket Depth: <br />15.25 14 <br />13.50 <br />Wait time between applying <br />vacuum/water and start of test: <br />- _ <br />- <br />Test Start Time (Tj): <br />100 100 <br />100 <br />Initial Reading (Rj): <br />14 13 <br />12 <br />Test End Time (TF): <br />200 200 <br />200 <br />Final Reading (RF): <br />14 13 <br />12 <br />Test Duration (TF — TI): <br />IHR IHR <br />IHR <br />Change in Reading (RF - R,): <br />0 0 <br />0 <br />Pass/ Fail Threshold or <br />Criteria: <br />Test Result: <br />® Pass ❑ Fail <br />Z. Pass " ❑Fail <br />Pass El`Fail <br />❑ Pass ❑ Fail <br />Comments — (include information 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 information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature <br />W Date 6-23-09 <br />' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local <br />requirements may be more stringent. <br />