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r <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report For <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 Narn( L Date of Testing: ` <br /> Facility Address: "70 1 /�s <br /> Facility Contact: t CA'11� Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(f present during testing): y h , <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.Nimmoavid A. Winkler E] Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: ❑ICC Service Tech. SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Mydrostatic ❑ Vacuum ❑Other <br /> Test Equipment Used: 2O— Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 )DT 3 4 <br /> Number, Stored Product, etc. / ) <br /> Bucket Installation Type: <br /> UP Direct Bury 001 Direct Bury <br /> ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in ❑Contained in <br /> Sump Sump <br /> Bucket Diameter: 13 3 <br /> Bucket Depth: ) <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): <br /> Initial Reading(Rq): Z f <br /> Test End Time(TF): E. <br /> Final Reading(RF): <br /> Test Duration(TF—TI). <br /> Change in Reading(RF-RI): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result. ,. ass, ❑F ass Y ,,❑Fail ❑ Pass .<.. ❑Fail El -s ' ❑Fail ``: <br /> Comments (include information on re <br /> pair'smade prior to to 'ng, and recommended follow-up for failed tests) <br /> CERTIFICATIONjinformion <br /> N RESPONSI E FOR CONDUCTING THIS TESTING <br /> 1 hereby certif r�eiat all ttained in this r port is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: ��—ZState laws and regulattly require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />