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SWRCB,January 2006 <br /> Spill Bucket Testing <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. ACID TI <br /> Facility Name: 1.)e- ` Date of Testing: <br /> Facility Address: %L v <br /> Facility Contact: )C- Phone: - - � <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(f present during testing): <br /> 2.TESTING CONTRACTOR FO TI N <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 M David A. Winkler ❑ Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': Tj ICC Service Tech. ❑ SWRCB Tank Tester O _ 17S5 <br /> 3.SPILL,BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: -- `�,t� ? V Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 f% 3 4 <br /> Number, Stored Product, <br /> Direct B Direct Bury ❑Direct Bury <br /> Bucket Installation Type: �' n Direct Bury ❑Contained in ❑Contained in <br /> ❑Contained in Sump ❑ Contained in Sump <br /> Sump Sum <br /> Bucket Diameter: <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): j vo 6) !C La tel <br /> Initial Reading(Ri): `7 3/k T / '" ' <br /> Test End Time(TF): //UU l rU l U C.) <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: 91 Pass ❑Fail ® Pass ❑Fair 21 Pass ❑Fail ❑ 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 con fined in this report is true,accurate,and in full compliance with legal reguiremr- ts. <br /> Technician's Signature: Date: a�- 3 <br /> State laws and regulations, o not currently require testing to be performed by a qualified contractor.However, local requirements <br /> may be more stringent. <br />