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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 FORM TION <br /> Facility Name: �� / %�" Date of Testing: - <br /> Facility Address: <br /> Facility Contact: &6&A Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector ff present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"d Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ❑ Zane A.Nimavid A. Winkler E] Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': C Service Tech. CB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑ Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: Equipment Resolution: <br /> —T <br /> Identify Spill Bucket(By'lank 1 2 3 4 <br /> Number, Stored Product, etc.) /OC <br /> ❑ ect Bury ❑ D' ect Bury F-1DirectBury ❑ Direct Bury <br /> Bucket Installation Type: Piraired in Sump ontained in Sump El Contained in F] Contained in <br /> Sump Sum <br /> Bucket Diameter: ( L <br /> Bucket Depth: L Z 1 <br /> Wait time between applying �._------- <br /> vacuum/water and start of test: <br /> Test Start Time(Tl): <br /> Initial Reading(Rj): <br /> Test End Time(TF): 00 <br /> Final Reading(RF): <br /> Test Duration(TF-Tl): <br /> Change in Reading(RF-RI): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ss ❑ Fail Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments-(include informa on on repairs made pr'or,to testing, and recarnnaended follow-up for failed tests) <br /> CERTIFICATION OF T CHNICIAN SPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the in rmation contain in this report' 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 />