Laserfiche WebLink
SWRCB, January 2006 <br />SIAI Bucket Testing Report Rorm <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: A i,11A,4 & rf Date of Testing: ®E . Z r - a <br />Facility Address:Z <br />Facility Contact: Phone: 2 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (fpresent during testing): <br />i I 1, 0 <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': ® ICC Service Tech. ® SWRCB Tank Tester <br />SPILL3. fET TESTING INFORMATION <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. = <br />1 No rZ <br />b 1 L <br />2 5o u <br />b <br />3 <br />4 <br />Bucket Installation Type: <br />Direct Bury <br />El Contained in Sump <br />® Direct Bury <br />E] Contained in Sump <br />❑ Direct Bury <br />❑Contained in <br />❑ Direct Bury <br />❑Contained inSump Sum <br />Bucket Diameter: <br />1 1 <br />1 1 <br />Bucket Depth: <br />0 8 <br />1 8 <br />Wait time between applying <br />vacuum/water and start of test:"— <br />Test Start Time (TI): <br />9 <br />9 ®cam <br />Initial Reading (RI): <br />l ` <br />6 <br />Test End Time (TF). <br />®® <br />bGlO <br />Final Reading (RF): <br />1-7 ' <br />j(0- <br />Test Duration (TF - TO: <br />N <br />Change in Reading (RF - <br />Pass/Fail Threshold or <br />Criteria: <br />Test.ResultsAn <br />Pass ❑Fail <br />;' Pass ❑Fail " <br />❑Pass :`; ❑Fall <br />❑Pass < ❑Fail <br />1,ummen`s - (rnctuae information on repairs made prior to testing and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSWULE FOR CONDUCTING THUS 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: 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 />2 <br />