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# 0 SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. I 1_Yr I►1 �,u. Y�►1 Facility Name: T01 Date of Testing: - Facility Address: Facility Contact: -L- I Phone: Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (f present during testing): L. I ES I IN kir U VN I MAL; I UK IN FORMATION Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo Q? David A. Winkler ❑ Felix G. Ramirez 5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT Credentials: ❑ ICC Service Tech. ®"S WRCB Tank Tester op -1-7_3.9 3. SPILL BUCKET TESTING INFORMATION Test Method Used: M'Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: _1(L+ Equipment Resolution: Identify Spill Bucket (By Tank Number, Stored Product, etc.) 12 9 3 4 iii f % O Bucket Installation Type: � Direct Bury El Contained in Sump ®Direct Bury El Contained in Sump —9=D irect Bury El Contained in Sum ® Direct �' D1/� ❑ Contai ed in Sum Bucket Diameter: 1 l Bucket Depth: Wait time between applying vacuum/water and start of test: — — - Test Start Time (T): OU yUU 5'00 ftJO UU Initial Reading (Rj): 13 11 i t 10 Test End Time (TF): i�Jp jQOJ 110 Do 1000 1 0 Final Reading (RF): U,i It I1 i p Test Duration (TF - Tj): 1 Change in Reading (RF - Rj): Pass/Fail Threshold or Criteria: — - srest Result: [$ Pass -❑ Fail Pass , ❑ Fail E Pass ❑ Fail M Pass A Ift COI MOS - (include information on repairs made prior to testing and recommendedfollow-up for failed tests) CERTIFICATION OF TE N RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all itmfor ation co tained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: Date: 1- 13-61 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.