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0 <br />0 <br />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 />S <br />2. TESTING CONTRACTOR INFORMATION 1 <br />Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) 744-0112 4.qTIO-6 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ❑ David A. Winkler ® Felix G. Ramirez <br />5249115 -UT 5263322 -Ur 5263373 -UT 5273934 -UT <br />Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />A CPTT.i, RITfKF.T TF.CTING INFORMATION <br />MIL <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: 1/16 <br />1 87 2 <br />3 <br />r„ <br />4 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Bucket Installation Type: <br />® Direct Bury <br />El Contained in Sump <br />E] Direct Bury <br />E] Contained in Sump <br />E] Direct Bury <br />❑ Contained in <br />Sump <br />E] Direct Bury <br />E] Contained in <br />Sum <br />Bucket Diameter: <br />17 <br />Bucket Depth: <br />22 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />Test Start Time (Ti): <br />1000 <br />Initial Reading (RI): <br />21 <br />Test End Time (TF): <br />1100 <br />Final Reading (RF): <br />21 <br />Test Duration (TF — TI): <br />1 HOUR <br />Change in Reading (RF - RI): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />_ <br />Test Result: <br />® Pass E] Fail <br />El Pass ❑ Fail <br />❑Pass El Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />®PW BUCKETS <br />LARGEEXTRA BUCKET <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS 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: <br />Date:07-18-14 <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 />