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%ill Bucket Testing Reportfol r M SWRCB,January*ry 2006 <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 ownerloperatorfor submittal to the local regulatory agency. <br /> Name: 1-FACILITY INFORMATION <br /> �� <br /> Facility <br /> Facility d KI <br /> Facility - Date of Testing: a <br /> Address: <br /> CA <br /> Facility Contact: <br /> xo;p A- #Aeem- Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ii(present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2n Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> mi <br /> Technician Conducting Test: ❑Lyle D.Nimmo [N. Zane A.Nimmo El David A. Winkler 0 Felix G. Ramirez <br /> 5249115-UT 5263322-UT UTJ <br /> 5263373-UT 5273934-UT <br /> [Credentials': Z1 ICC Service Tech. SWRCB Tank Tester <br /> 3.SPILL.BUCKET TESTING INFORM ATION <br /> Test Method Used:—... F]Hydrostatic Vacuum [Q] ther <br /> Test Equipment,, , I U I sed Equipment Resolution: <br /> Identify Spill Bucket(By Tank 2 3 4 <br /> T <br /> T <br /> Test <br /> Test s <br /> s <br /> t <br /> t <br /> M <br /> Method <br /> o <br /> d <br /> Used: <br /> Used, '4 '6 <br /> Number,Stored Product, etc. — 171 biE <br /> ®Direct B Direct B <br /> Bucket Installation Type: Direct Bury Direct Bury Sump Co Bury Bury <br /> ❑Contained in El Contained in <br /> EEI Contained in Sump El Contained in SUMP Sum <br /> Bucket Diameter: t I Sump- Sump <br /> Bucket <br /> 'I n 4'. <br /> ucket Depth: f3 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI); —8 45 <br /> Initial Reading(RI): /,Z T+ -- 17- <br /> f Zr <br /> Test End Time(TF)- oc <br /> Final Reading(RF): <br /> Test Duration(TF— <br /> Change in Reading(RF-RI): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: pass E] <br /> Fail —PassEl Fail Pass 0 Fail El Nss El Fail:1 <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 informa:jbn co i ed in this report is true,accurate,and in full compliance with legal requi ments. <br /> Technician's Signature: 11 06 <br /> Date: -5 a 06 <br /> 7�/ <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 />