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0 0 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(ifapplicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: tocic- Date of Testing: Y-Z -cf-- <br /> Facility Address: /?t,)/ 4,)- <br /> Facility Contact: M.0 el I Phone: za, 9kd:--- Z411/13� <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ii(present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFF RDA TEST 416 2"'Street Gait,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: Ej Lyle D.Nimmo E] Zane A.Nimmo [jfl David A. Winkler F-1 Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': E ICC Service Tech. F2] SV*rRCB Tank Tester Of- - I VF <br /> 3. SPELL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic El Vacuum F1 Other <br /> Test Equipment Used: 024- Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 23 4 <br /> Number,Stored Pr 91 <br /> g Direct Bury Direct Bury El Direct Bury ❑Direct Bury <br /> Bucket Installation Type: E]Contained in Sump El Contained in SUMP [:1 Contained in El Contained in <br /> Sump Sump <br /> Bucket Diameter: jr <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): I.Ao 0 -AQ;V /I U 0 <br /> Initial Reading(RI): 17 /Z- /?- <br /> Test End Time(TF)-. /Yo 0 <br /> Final Reading(RF): 3 1 Z-71-t <br /> Test Duration(TF-TI): {1f- <br /> Change in Reading(RF-RI): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: Pass ❑Fail Pass El Fail [:1 Pass El Fail El Pass Ej Fail <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TEC IA SPONSIBLE FOR CONDUCTING THIS TESTING <br /> CIA <br /> el <br /> I hereby certify that all the inform ion contai ed in this report is true,accurate,and in full compliance with legal requiremenW <br /> Technician's Signature: Date: <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> Z� <br /> may be more stringent. <br />