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t Y <br /> ' SWRCB,January 2006 <br /> Spill Bucket Testing Report For <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 /> Facility Name: } . .=,V k 'F Date of Testing: b) QC) <br /> Facility Address <br /> Facility Contact: U'e{4 Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(f present during testing) <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: [I Lyle D.Nimmo ❑ Zane A.Nimmo [I David A.Winkler Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT V 5273934-UT <br /> Credentials': CC Service Tech. SWRCB Tank Tester <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: t kt p A, tv Equipment Resolution: ' b <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number,Stored Product, etc. <br /> 1:1 Direct Bury ❑Direct Bury <br /> Bucket Installation Type: Direct Bury ❑Direct Bury <br /> RContained in Sump ❑ Contained in Sump El Contained in El Contained in <br /> Sump Sum <br /> Bucket Diameter: j <br /> Bucket Depth: 2-' <br /> r� <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): <br /> Initial Reading(RI): {2 <br /> Test End Time(TF): 2 5 C;) <br /> Final Reading(RF): 0 <br /> Test Duration(TF—TI): C.% <br /> Change in Reading(RF-R j): 2 <br /> Pass/Fail Threshold or <br /> Criteria: r. <br /> Test Result: ❑ Pass Fail ❑ Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information,on reparrs m de prior to testing, and recommended follow-up for failed tests) <br /> C,1 C <br /> CERTIFICATION OF C CIAN RESI'ONSII3LE FOI�YCONDIJCTING THIS TESTING <br /> I®rreby certify that all the in rma n contained in'tbis report i `true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date:O J2.3 zl.) <br /> l <br /> ' State laws and regulations o not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. -- <br />