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t :f <br />EB O V , January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill containme `"W9190 7 rm and <br />printouts from tests (applicable), should be provided to the facility owner/operator for submittal to -the iocaI regulatory agency. <br />I- FAC..II.ITV INFORMATION <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 9 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />m,...a L`,...:.....o..t T T—A- h )A Anil tans —pneim- I EaUiDment Resolution: 1/16 <br />Identify Spill Bucket (By Tank 1 87 2 3 DSL <br />Number, Stored Product, etc. <br />4 <br />Bucket Installation Type: ®Direct Bury <br />❑ Contained in Sump <br />E] Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: 11 <br />11 <br />Bucket Depth: 14 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />-- <br />Test Start Time (TI): 956 <br />956 <br />Initial Reading (Ri): 14 <br />14 <br />Test End Time (TF): 1056 <br />1056 <br />Final Reading (RF): 11 <br />12 <br />14.40 <br />Test Duration (TF — Tj): IHR <br />IHR <br />1 HR <br />Change in Reading (RF - Rl): 0 <br />0 <br />0 <br />Pass/Fail Threshold or 1/16 <br />Criteria: <br />1/16 <br />1/16 <br />Test Result: I ®Pass ❑ Fail <br />[] Pass ; ❑ Fail <br />0 Pass ❑ Fail <br />❑ Pass ❑ Fain <br />Comments — (include information on repairs made prior to testing and recommended follow-up for failed tests) <br />OPW <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE 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 requirements. <br />Technician's Signature: T -6—j <br />Date 1-23-15 <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 />