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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> Thisforn Is intendedfor use by contractors performing annual testing of USTspill containment structures. The completedform and <br /> printouts from tests (if applicable), should beprovided to the facility owner/operator for submittal to the local regulatory agency. <br /> I.FACILITY INFORMATION <br /> Facility me: SYSTEM TRANSPORT Date of Testing: 5/24/11 <br /> Facility Ao dress: 707 E. ROTH RD. FRENCH CAMP, CA 95231 <br /> Facility C ntact: Phone: <br /> Date Local Agency Was Notified of Testing:5/4/11 <br /> Name of Local Agency Inspector(ifpresent during testing): TWI <br /> 2. TESTING CONTRACTOR INFORMATION <br /> CompanyName: AFFORDA TEST 4162 nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technicia Conducting Test: ❑ Lyle D.Nimmo N 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: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket (By Tank 11 1 2 3 4 DILSLI, <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: ElDirect Bury El Direct Bury Direct Bury Direct Bury ❑ Contained in ❑Contained in <br /> E]Contained in Sump ❑ Contained in Sump <br /> Sumn Sum <br /> Bucket Diameter: 12 <br /> Bucket De the 10 3/4 <br /> Wait time between applying <br /> vacuum/water and start of test: -- <br /> Test Start Time(TI): 1530 <br /> Initial Rea ing(111): 9 3/4 <br /> Test End T e(TF): 1630 <br /> Final Readi g(RF): 9 3/4 <br /> Test Duration(TF—Tj): HR HR HR HR <br /> Change in Reading(RF-Rj): 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Resu h ❑ Pass ❑ Fail I ❑ Pass ❑Fail ❑', Pass E] Fail ® Pass <br /> ❑ Fail <br /> TCommen s— (include information on repairs made prior to testing, and recommended ollow-u or ailed tests) <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: — Date: 5/24/11 <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 />