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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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> - 1.FACILITY INFORMATION <br /> Facility Name: 1 IDate of Testing: — <br /> Facility Address: 13?) 5 - AnniJ to t Cil <br /> Facility Contact: i'n i 1 Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209) 744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo r-1ZaneA.Nimmo David A. Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: ❑ ICC Service Tech. �rVTRCB Tank Tester & 2- <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: 52niydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: r /� > f� �'� Equipment Resolution: <br /> Identify Spill Bucket(By Tank l r 2 (, 3 4 <br /> Number, Stored Product, etc.) 1 0S L <br /> ® Direct Bury ❑Direct Bury <br /> ® Direct Bury ® Direct Bury El Contained in ❑Contained in <br /> Bucket Installation Type: ❑Contained in Sump ❑ Contained in Sump gum Sum <br /> Bucket Diameter: Z 12— <br /> Buck-,t <br /> 2— <br /> Bucket Depth: i i Z-') <br /> Wait time between applying <br /> vacuum/water and start of test: _ <br /> Test Start Time(Ti): v <br /> Initial Reading(Rj): <br /> Test End Time(TF): <br /> Final Reading(RF): <br /> Test Duration(TF—Tl): I A <br /> Change in Reading(RF-Ri): <br /> Pass Fail Threshold or <br /> Criteria: <br /> Test Result: 'Pass ❑ Fail ass El Fail Pass El Fail El Pass [:1 Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TEC NICIAN RES NSIBLE FOR ONDUCTING THIS TESTING <br /> 1 hevt�;y certify that all the infor ation contained in is report is tr e,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: <br /> State laws and regulations do t currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />