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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 /> Facility Name: EMILS 76 1 Date of Testing: 5-3-12 <br /> Facility Address: 1405 CALIFORNIA ST ESCALON CA <br /> Facility Contact: LINDA Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpreseni during testing): JEFF <br /> 2. TESTING CONTRACTOR INFORMATION <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 /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑vacuum ❑Other <br /> Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DSL 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury El Direct Bury <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury ❑Contained in E]Contained in <br /> E]Contained in Sump ❑Contained in Sump Sum Sum <br /> Bucket Diameter: I I 11 11 <br /> Bucket Depth: 12 12 14 <br /> Wait time between applying _- <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 9 9 9 <br /> Initial Reading(R,): I 1 11 13 <br /> Test End Time(TF): 10 10 10 <br /> Final Reading(RF): 11 11 13 <br /> Test Duration(TF—T,): IHR IHR IHR <br /> Change in Reading(RF-R,): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: Pass ❑Fail ® Pass ❑Fail ® Pass ❑Fail ❑ Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recornmendedfollow-upforfailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> ��� <br /> Technician's Signature: ... Date 5-3-12 <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 />