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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(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION `r <br /> Facility Name:Uv�� Date of Testing: <br /> Facility Address: , �� - t „S� <br /> Facility Contact: Phone: Z o F <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): r c <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 ❑ Zane A.Nimmo avid A. Winkler 9L Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: XICC Service Tech. CB Tank Tester 3 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®.Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: T1a Z 0 Equipment Resolution: <br /> Identify Spill Bucket(By TaEl 2 3 4Number, StoredProduct, etcBury ®Direct Bury Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑Contained in ❑Contained in <br /> ned in Sump ❑Contained in Sump <br /> Sump Sum <br /> Bucket Diameter: I <br /> Bucket Depth: 13 <br /> - <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): ;1 , <br /> oInitial Reading(RI):Test End Time(TF): <br /> Final Reading(RF): i Z <br /> Test Duration(TF—Tt): <br /> Change in Reading(RF-Rj): <br /> Pass/Fail Threshold or <br /> Criteria: . <br /> Test Result: J Pass ❑Fail Pass ❑Fail ElPass ❑Fail —E] Pass ❑Fail <br /> Comments—(include informatio repairs made prior to testing and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNIC RESP NSIBLE'FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is tru¢,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: <br /> / .� Date: � U ' <br /> State laws and regulations do nVicurrently,require testing to be performed by a qualified contractor.However, local requirements <br /> may be more stringent. <br />