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q V <br />C <br />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 4162 d 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 I <br />3_ SPILT, RUCKF,T TESTING INFORMATION <br />Test Method Used: <br />® Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: h20 and tape measure <br />n_ _.. <br />Equipment Resolution: 1/16 <br />- , 9.�,. � �,,%., �. <br />Identify Spill Bucket (By Tank <br />.ms=9.1=111=0ti��.. <br />1 87 <br />,,�; <br />2 91 <br />3 DSL <br />4 <br />Number, Stored Product, etc. <br />Bucket Installation Type: <br />❑ Direct Bury <br />❑ Direct Bury <br />❑ Direct Bury <br />® Contained in <br />El Direct Bury <br />❑ Contained in <br />® Contained in Sump <br />® Contained in Sump <br />Sump <br />Sum <br />Bucket Diameter: <br />I 1 <br />11 <br />11 <br />Bucket Depth: <br />13.50 <br />13.50 <br />13 <br />Wait time between applying <br />_- <br />-- <br />vacuum/water and start of test: <br />Test Start Time (TO: <br />9 <br />9 <br />9 <br />Initial Reading (Ri): <br />12 <br />12.50 <br />12 <br />Test End Time (TF): <br />10 <br />10 <br />10 <br />Final Reading (RF): <br />12 <br />12.50 <br />12 <br />Test Duration (TF —TI): <br />IHR <br />IHR <br />IHR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />1/16 <br />1/16 <br />1/16 <br />Criteria: <br />Test Result: <br />® Pass ❑ Fail <br />Z Pass ❑ Fail <br />1 Z Pass < ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up jor jailea 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: <br />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 />