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s • r a,..., M e-. <br /> 2_I RCB,January 2006 <br /> Spill Bucket Testing Report Form _ qq <br /> This form is intended for use by contractors performing annual testing of UST spill c iib@ werm and <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submjl h�:* 7060 Nifulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Tulare Farms I Date of Testing: 1-17-17 <br /> Facility Address: 2771 E FRENCH CAMP RD FRENCH CAMP CA <br /> Facility Contact: Mike Phone: <br /> Date Local Agency Was Notified of Testing:12-22-16 <br /> Name of Local Agency Inspector(if present during testing): STACY <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 ❑ Zane A.Nimmo ® David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ®ICC Service Tech. ®SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br /> 'Z... "_= .a,,. - �.,.,.t w,M. r., 5e.. ." ,.•moi,iu.ti a.� ..,,¢i'� 0i�' Y <br /> Identify Spill Bucket(By Tank 1 87 2 3 DSL 4 <br /> Number,Stored Product, etc. <br /> ®Direct Bury El Direct Bury ®Direct Bury El Direct Bury <br /> Bucket Installation Type: ❑Contained in Sump ❑Contained in Sump ❑Contained in ❑ Contained in <br /> Sump Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 2 2 <br /> Initial Reading(Rj): 14 14 <br /> Test End Time(TF): 3 3 <br /> Final Reading(RF): 14 14 <br /> Test Duration(TF—Ti): IHR IRR IHR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 <br /> NCriteria: <br /> 'Test Result: 0 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 /> 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: Date 1-17-17 <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 />