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SWRCB, January 2006 <br />Spill Banlawt 'fest ng Report 'onra <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 (tf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />Facility Name:/ c-✓ i G ,2— Date of Testing: 5 Z v <br />Facility Address: ,9ie , �F- g- w <br />Facility Contact: Phone: Zn p <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): peg �z <br />2_ TF.STfNG 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. Nimmo4k David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />11 Credentials': ❑ ICC Service Tech. ® SWRCB Tank Tester ( ��'7-SY 11 <br />z run a udTi' IV C'r 9rlh'C-rMg-- TlVrnI?lt4 A TInN <br />Test Method Used: lYHydrostatic ❑ vacuum ❑ Other <br />Test Equipment Used: Al Zo <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 .-, <br />Bury <br />El Contained <br />❑ Contained in Sump <br />2 <br />El Direct Bury <br />El Contained in Sump <br />3 - <br />❑ Direct Bury <br />❑Contained in <br />Sum <br />4 y, . <br />F1 Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Installation Type: <br />Bucket Diameter: <br />"' <br />Bucket Depth: <br />/ S " <br />JS <br />Wait time between applying <br />vacuum/water and start of test: <br />'— <br />Test Start Time (Ti): <br />Initial Reading (Rj): <br />Test End Time (TF): <br />Final Reading (RF): <br />ZZ <br />Test Duration (TF - Tj): <br />2 <br />Change in Reading (RF - Rj):-�- <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />t3 Pass ❑ Fail <br />Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments - (include information on repairs made prior to testing and recommended jotlow-up jor jaitea tests] <br />CERTIFICATION OF <br />I hereby certify that all the in <br />Technician's Signature: <br />BLE FOR CONDUCTING THIS TESTING <br />report is true, accurate, and in full compliance with legal requirements. <br />"�..� Date: / S� <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 />