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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 Name: ® 16 Date of Testing: -6+ <br /> Facility Address: �y'° I Q o CA <br /> Facility Contact: ® ► Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(f present during testing): j1 j <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo X David A. Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': X 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 23 4 <br /> Number, Stored Product, etc.) (JC } /(, .-� <br /> Bucket Installation Te ER Direct Bury direct Bury Direct Bury F-1DirectBury <br /> yp ❑ Contained in Sump ❑ Contained in Sump Contained in ❑ Contained in <br /> Sum Sump <br /> y Bucket Diameter: �t � ! /> <br /> Bucket Depth: ( ° �� d YL <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): <br /> Initial Reading(Rj): y 0 ; <br /> Test End Time(TF): �, — <br /> Final Reading(RF): 6t i11 <br /> Test Duration(TF—Tz): hk 7� <br /> Change in Reading(RF-RI): { <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Results Dr,Pass ❑Fail 1?ass ❑FailPass <br /> El Fail El Pass El Fail <br /> '1 2Comments—(include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> CERTIFICA6ure: <br /> TECHNICIAN ESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify thaformation contai ed in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's SignDate: --z <br /> ' State laws and redo not currently require testing to be performed by a qualified contractor. However, local requirements <br /> may be more stringent. <br />