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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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <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 ❑ David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum F1 Other <br />Test Equipment Used: TAPE MEASURE, <br />H2O <br />1 OLD DIESEL <br />❑ Direct Bury <br />®Contained in Sump <br />2 <br />❑ Direct Bury <br />El Contained in Sump <br />Equipment Resolution: 1/16" <br />3 NEW DIESEL 4 NEW DIESEL <br />REMOTE FILL TANK FILL <br />Direct Bury Direct Bury <br />® Contained in ® Contained in <br />Sump Sum <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.2 <br />Bucket Installation Type: <br />Bucket Diameter: <br />11 <br />11 11 <br />Bucket Depth: <br />13 3/4 <br />14 3/4 16 1/4 <br />Wait time between applying <br />vacuum/water and start of test: <br />-- <br />Test Start Time (TI): <br />0945 <br />1300 1225 <br />Initial Reading (Rj): <br />12 3/4 <br />14 1/8 16 -- <br />Test End Time (TF): <br />1045 <br />1400 1325 <br />Final Reading (RF): <br />12 3/4 <br />14 1/8 16 -- <br />Test Duration (TF — Tj): <br />HR <br />HR <br />HR HR <br />Change in Reading (RF - RI): <br />0 <br />0 0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result; <br />® Pass Orail <br />Fail <br />®Pass Fail ` ®Pass ❑Fail' <br />Comments —(include information on repairs made prior to testing, and recommendedfollow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: Date:10-11-11 <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 />