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SWRCB,January 2006 <br /> St)41I Bucket Testing Report Form <br /> This form is intended for use by <br /> ntractors should be provided to the facorming annual testing <br /> l tty owner/operator for submittal to the local regulatnment structures. The ory ge and <br /> printouts from tests(if applicable), p <br /> 1.FACILITY INFORMATION _ <br /> 05/ <br /> i C Date of Testing: z 7 D <br /> Facility Name: <br /> Facility Address:51113 <br /> Facility Contact: V Ymc, Phone: <br /> Date Local Agency Was44otified of Testing: p I v <br /> Name of Local Agency Inspector(if present during testing: `-�.,;;. �-, , ��;.,t� t�+ ,:-.•:� —- - - <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORD.TEST 416 2"d Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test <br /> F1 Lyle D.Nimmo E] Zane A.Nimmo El 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 /> WTestMethod Used: ydrostatic ❑ vacuum ❑Other <br /> Equipment Used: = Equipment Resolution:fy Spill Bucket(By Tank l - i 2 3 4 <br /> Number, Stored Product, etc.). `) L �) <br /> Direct Bury Direct Bury <br /> Bucket Installation Type: Direct Bury Direct Bury ❑Contained in ❑Contained in <br /> ❑Contained in Sump ❑Contained in Sump SumpSum <br /> Bucket Diameter: I ( 1 t <br /> Bucket Depth: ��9 3 4 A /L.._ <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): <br /> Initial Reading(RI): 3 , �- <br /> Test End Time(TF): 14so } L\3 b <br /> Final Reading(RF): 11 ' V2 <br /> Test Duration(TF—TI): ` p VAu 0 Y v U r <br /> Change in Reading(RF-Rl): <br /> Pass/Fail Threshold or <br /> Criteria: --- <br /> Test Result: ' Pass ❑ Fail f" Pas ❑ Fail Pass ❑ Fail ❑ Pass L] Fail <br /> Comments—(include informat oil n repairs made prior to testing, and recommendeztf�llow-up Jor failed tests) <br /> CERTIFICATION TE HNICIAN RESPONSID - OR CONDUCTING THIS TESTING <br /> I hereby eer6t�that all the for ation eonta} in this ta6rt is trn rate, din full compliance with legal requirements. <br /> i r <br /> Technician's Signature: dr` �yL. m <br /> Date:O5 State laws and regulations o not currently requperfo by a qualified contractor.However,local requirements <br /> may be more stringent. <br />