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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 a d <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: „ I Date of Testing: 'Q <br /> Facility Address: f- �'fyJMOM& �Lo14 64 <br /> Facility Contact: 250 6)" l Phone: _ <br /> Date Local Agency as Notified of Testing: <br /> Name of Local Agency Inspector(rf present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162"d Street Galt,CA 95632 1 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo ® David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: A ICC Service Tech. JM SWRCB Tank Tester <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: - .®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Z _ Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number,Stored Product, etc) Of(— <br /> Bucket Installation Type: Direct B ®Direct Bury F1 Direct Bury <br /> yp Bury ®Direct Bury ❑Contained in ❑ Contained in <br /> ❑Contained in Sump ❑Contained in Sump <br /> SumpSum <br /> Bucket Diameter: / 1 !/ I I <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 13-7U 13-70 1 33 U <br /> Initial Reading(Rj): !3 /7- <br /> Test <br /> -Test End Time(TF): <br /> Final Reading(RF): !1 <br /> Test Duration(TF—Tj): / A, <br /> Change in Reading(RF-Rj): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: Pass ❑Fail Pass ❑Fail Pass ElFail <br /> [:1,Pass ElFadi <br /> Comments—(include information on repairs made prior to testing, and recommended follow-u for failed tests) <br /> CERTIFICATTON OF TEC ICIAN RES NSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the informati w ontained i this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: U� <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 />