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SWRCB,January 200b <br /> 6PW BucketTesting Report Forma <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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> I.FACILITY INFORMATION <br /> Facility Name: t 1 Date of Testing: j--j;7—Cg" <br /> Facility Address: <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(rf present during testing): y <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: <br /> E]Lyle D.Nimmo El Zane A.Nimmo David A. Winkler E] Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ❑ICC Service Tech. 91 SWRCB Tank Tester (;QJ-- 173F <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Q Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: �- A; Equipment Resolution: <br /> Identify Spill Bucket(By T1413 <br /> 2 3 4 <br /> Number, Stored Product, et <br /> ®Direct Bury ®Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ❑Contained in ❑ Contained in <br /> Sump ❑ Contained in SumpSum SumBucket Diameter: / III <br /> Bucket Depth: 11 j 7 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T): y U,1 Q <br /> Initial Reading(RI): 4- 1 <br /> Test End Time(TF): <br /> Final Reading(RF): ��►� iL <br /> Test Duration(TF—Tj): / <br /> Chan9e in Reading(RF-Rj): �t f �/ <br /> Pass/Fail Threshold or <br /> Criteria: �-- <br /> Test Result: ass ❑Fail ❑ Pass DiTail ass ❑Fail ❑ Pass ❑Fail <br /> COmmentS— (include information on repairs made prior to testing,, and recommended follow-u for failed tests) <br /> 1 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information con n this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date:_ <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 />