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Spill Bucket Testing Report Form SWRCB,January 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 ownerfoperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ( ', Date of Testing: <br /> Facility Address: <br /> Facility Contact: .4 C `=. Phone: <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(rf present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> IM Lyle D.Nimmo ❑ Zane A.Nimmo <br /> Technician Conducting Test: ❑ David A. Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': E ICC Service Tech. Q 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 2 3 4 <br /> Number, S ored Product, etc.J ` t <br /> a t_ <br /> Bucket Installation Type: ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ❑ Contained in Sump ❑Contained in Sump ❑ Contained in El Contained in. <br /> Sum Sum <br /> Bucket Diameter: <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): i-5 <br /> Initial Reading(Rj): i 7S *' <br /> Test End Time(TF): tj C1 7— <br /> Final <br /> Final Reading(RF): <br /> Test Duration(TF—Ti): .,- <br /> Change in Reading(RF-RF): , <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: `[] ,Pass [] Fail Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> COMMents—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION 04,2F.ECHNIC1AN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certify t atall the information contaiged in this report is true,accurate,and in hell compliance with legal requirements. <br /> Technician's Signature:—L44� (V Date: <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 />