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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 LIST spill containment structures. The completed form and <br /> printoutsftom tests (if applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> I.FACILITY INFORMATION <br /> Facility Name: a, E7 Date of Testing: <br /> Facility Address: <br /> Facility Contact:- Phone: <br /> Date Local Agency Was Notified of Testing: -;7- cc'�j <br /> Name of Local Agency Inspector(if'present during testing): r r 70 <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: [XLyle D.NimmoEl Zane A.Nimmo E] David A. WinklerEl Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': El ICC Service Tech. 'Ll SWRCB Tank Tester <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic F] Vacuum 0 Other <br /> Test Equipment Used: <br /> Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) <br /> r-1 Direct Bury 0 Direct Bury F�Direct Bury Ej Direct Bury <br /> Bucket Installation Type: F1 Contained in Sump ❑ Contained in Sump El Contained in F1 Contained in <br /> Sump Sump <br /> Bucket Diameter: <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): <br /> Initial Reading(RI): <br /> Test End Time(TF): <br /> Final Reading(RF): <br /> Test Duration(TF—Tj): <br /> Change in Reading(RF-RI): ` <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ❑ Pass E] Fail E] Pass El Fail El Pass EJ Fail El Pass El Fail I <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> 0 <br /> 7—n <br /> 2"',e.0 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that s,,%,R-the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> tt <br /> Technician's Signature: <br /> 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 />