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UL/'Ly/•Lulu FRI lb: L4 PAX LUY4bUZ$4.33 SJU ZMW <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual to sting 9fIJST al;,ill containment vruc•tza-es. The completed form crud <br />Printo(as from tests (f applicable), should be provided to the facility owner/operato)•,for szibnzittal to the local r-egWato1), agency. <br />1. FACI111TV INFORMATION <br />TESTING CONTRACTOR INFORMATION <br />Company Name: AFF012DA TEST 416 2"d Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-01 16 <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 I <br />pCredentials_ ® IGC Service "Tech. iJZ SWIZCB "Tank -fester <br />3. SPILL BUCKET TESTING INFORMATION <br />p 1 est lvletnoa Used: � Hydrostatic U Vacuum ❑Other <br />Test Equipment Used: h20 and <br />tape measure <br />^� <br />� P_quipment Resolution: 1/16 Y <br />Identify Spill Bucket (By Tangy <br />1 87 2 91 <br />i 3 4 <br />Nzrmber, .S�ored Product, etc. <br />1 <br />' Bucket Installation Type: <br />® Direct Bury ® Direct Bury <br />1 <br />❑Direct 13uty Direct Bury <br />❑ Contained in ❑ Contained in <br />❑ Contained in Sump ❑ Contained in Sump <br />_ ._ <br />Suitt Sump <br />Bucket Diameter: <br />Bucket Depth: <br />-Wait <br />17 <br />19 <br />time between applying <br />vacuum/water and start of test: <br />_ <br />- <br />'fest Start Time {"I'i): <br />1200 <br />1200 <br />III itiai Reacting (Rt): <br />16 <br />17.50 <br />Test End Time (T,:): <br />1300 <br />1304 �^ <br />�- <br />Final Reading (Rt:): <br />16 <br />17.50 <br />Test Duration (Tr: - T)): <br />11-lR <br />1 FIR <br />Change in Reading (Rr. Rr): <br />0 <br />0 <br />Pass/Fail 'threshold or <br />Criteria: <br />1/16 <br />1/16 <br />j�Test I2esu1t: <br />®Pass ❑Fail <br />®Pass Fail' <br />Pass ❑Fail <br />❑ Pass ❑ Fail- <br />��v,■aIAA! iHab — (rnauae rnlormanon on repairs• made prior to testing, and recommended fallow -up for failed tests) <br />yJ� <br />'Mil ICATION Or TECHNICIAN RESPONSWEE FOR CONDUCTING 1111. •1'IiSI'iNC; <br />1 Hereby certify that atl the ittforattalion contained in (itis report is true, accurate, and in full cotnpliattce with legal requirentcuts. <br />Technician's Signature: <br />Date 1-5-10 <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 />L000/L0001A <br />9T10 tVL 60Z XVd 9T:9T OTOZ/SO/ZO <br />