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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 <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 <br />(209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: <br />❑ 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. 0 SWRCB Tank Tester <br />Test Method Used: <br />3. SPILL BUCKET TESTING INFORMATION <br />Hydrostatic ❑ vacuum Lj Other <br />Test Equipment Used: h20 and tape measure <br />Identify Spill Bucket (By Tank 1 87 2 91 <br />Number, Stored Product, etc) <br />Equipment Resolution: 1/16 <br />3 DSL 4 <br />Bucket Installation Type: <br />❑Direct Bury Direct Bury <br />10 Contained in Sump Contained in Sump <br />Direct Bury Direct Bury <br />Contained in ❑ Contained in <br />Sump Sum <br />Bucket Diameter: <br />11 11 <br />11 <br />Bucket Depth: <br />13.50 13.50 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Tj): <br />9 9 <br />9 <br />Initial Reading (Rj): <br />12 12.50 <br />12 <br />Test End Time (TF): <br />10 10 <br />10 <br />Final Reading (RF): <br />12 12.50 <br />12 <br />Test Duration (TF — Tj): <br />IHR 1 HR <br />IHR <br />Change in Reading (RF- Rj): <br />0 0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 1/16 <br />1/16 <br />Test Result:- <br />Pass 0 Fail 0 Pass ® Fail <br />1 0 Pass []Fail ❑ Pass []Fail] <br />Comments — (include information on repairs made prior to testing, and recommended follow-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 12-7-2011 <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 />