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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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: r- 4-s' , ? , Date of Testing: . 3 -1) <br /> Facility Address: 1C}e N 14'h rt' <br /> VA 64 44 <br /> Facility Contact: _.'Toe G, Phone: <br /> Date Local Agency Was Notified of es g <br /> Name of Local Agency Inspector(f present during testing): " <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd 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: N ICC Service Tech. SWRCB Tank Tester <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑Hydrostatic ❑ Vacuum ❑Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 <br /> Number, Stored Product, etc. a" <br /> ®Direct Bury �Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type- ❑Contained in ❑Contained in <br /> ❑Contained in Sump ❑Contained in Sump <br /> Sump Sum <br /> Bucket Diameter: I <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test S G i Time(TI): 3 <br /> Initial Reading(RI): <br /> Test End Time(TF): <br /> Final Reading(RF): <br /> Test Duration(TF—TI): <br /> Change in Reading(RF-Rl): Vfj <br /> Pass/Fail Threshold or <br /> Criteria: <br /> ,-Test Result- Pass ❑Fail ] Pass ElFail E] Pass ElFail ❑ Pass El Fail <br /> Comments—(include information on repairs made prior to testing and recommended follow-u for failed tests) <br /> CERTIFICATION OF TECI-INICIA SPONSIBLE FOR CONDUCTING THIS TESTING <br /> —_,___ _ __ _ _ — _ _ _._ _ ___�.-..-- -------__—_ __.----- <br /> v I hes eby certify that all the information contains in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: L " <br /> I 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 />