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SVrRCB,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 beprovided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> ,—,1.FACILITY FO TION <br /> Facility Name: 76 1 Date of Testing: dF' <br /> Facility Address: Y/t)o 1--K--e/yx 0,t4 -S r"V- CA <br /> Facility Contact: Jt(,V I Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2 d Street Galt,CA 95632 1 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: E]Lyle D.Nimmo n Zane A.Nimmo niV David A.Winkler E] Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': R ICC Service Tech. SWRCB Tank Tester <br /> 3.SPELL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic EI Vacuum El Other <br /> Test Equipment Used: 0) 4-^ Equipment Resolution: <br /> ......... <br /> Identify Spill Bucket(By Tank 1 23 <br /> Number,Stored Product, etc.) �P/ ar <br /> FE]Direct Bury W]Direct Bury [g Direct Bury El Direct Bury <br /> Bucket Installation Type: El Contained in Sump El Contained in Sump E]Contained in E]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): P 12- Li 0 12, 11 L) <br /> Initial Reading(RI): f 1 L I <br /> Test End Time(TF): Ll c) <br /> Final Reading(RF): <br /> Test Duration(TF—Tj): <br /> Change in Reading(RF-RI): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test,R6§ult: El Fail L 10 Pass E]Fail� Pass El Fail E] Pass El Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> AP <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the informatio his eport is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: ' 'Y, Date: 1'/-- <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 />