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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 UST spill containment structures. The completed form and <br /> printouts from tests(if applicable),should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 1.FACILITY TION <br /> Facility Name: �Q A6 Date of Testing: <br /> Facility Address: ®® 7 ® dryCps. q <br /> Facility Contact: eta Phone: Zc,9 4 - Z <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(rf present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo 91 Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': M ICC Service Tech. SWRCB Tank Tester <br /> 3. SPH L BUCKET TESTING INFORMATION <br /> Test Method Used: afl Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: 7rA Equipment Resolution: , " <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc. <br /> 471 —2je:5611 <br /> Direct Bury Direct Bury Direct Bury Direct Bury <br /> Bucket Installation Type: Contained in Sump Contained in Sump ❑Contained in ❑Contained in <br /> Sump Sum <br /> Bucket Diameter: <br /> Bucket Depth: ` 15 Y7-- <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): <br /> Initial Reading(RI): p IlZ 14 12.. <br /> Test End Time(TF): 1 '4 <br /> Final Reading(RF): r o r <br /> Test Duration(TF—TI): <br /> 14 P, 149- <br /> Change in Reading(RF-RI): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: (,$� Pass ❑Fail;, -` Pass ❑Fail' ( Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF T�G-HN`dICIAN RESPONSMLE 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 r uir ents. <br /> Technician's Signature: Date: VA® 0 <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 />