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I S''v�f1�C13, January 2006Sf A21 ucket ` e t�ing Re art Fo.ri � <br /> This forth it intended for use by contractors performing annual testing of UST spill containment structures. The completed fore'a17d <br /> printouts from tests(rf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency:. <br /> 1.FACILITY INFORMATION <br /> Facility Name: G - t Date of Testin <br /> g0 7 Z p <br /> Facility Address: zjjG 1Jc,( v l C L4 2 <br /> Facility Contact: it) Phone: OG' <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(rf present during testing: A,\ <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"d Street Galt,CA 95632 (209)744-re <br /> 2 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A. Winkler Xlix 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: `7 ?i> Equipment Resolution: <br /> Identify Spill Bucket(By Tangy I 2 � 3 <br /> r Number, Stored Product, etc. 4� ;, 4 > 1 <br /> ❑Direct B ❑Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: �' ❑Direct Bury Contained in (Containedd in <br /> ']i Contained in Sump Contained in Sump Sum <br /> Sum <br /> Bucket Diameter: �� I 1 <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): `D I o 5 5 <br /> Initial Reading(RI): '� Z z 2 1J I y <br /> Test End Time(TF): d s1 2 p Z ( U rj 5 <br /> Final Reading(RF): Z V/ 2 2 l y <br /> Test Duration(TF—T!): (j u <br /> Change in Reading(RF-R!): <br /> Pass/Fail Threshold or <br /> Criteria: - ,— <br /> Test Result: Pass ❑Fail ( Pass ❑Fail ;" Pas ❑Fail 7 Pas ❑Fail <br /> Comments—(include informa o repairs made prior to testing, and recomme`n'�ed Slow-up forfaile test.) <br /> CERTIFICATION OF T CIAN RESPONSIBL- CONDUCTING THI TES!lk <br /> I hereby certify that all the info a n cont me it thisyrepor isfte,accurate,and in f 11 compliance with legal requirements. <br /> Technician's Signature: Date: d-� Z <br /> 1 State laws and regulations do n t currently require tes ' to be pe rf r-med by a qualified contractor.However,local requirements <br /> may be more stringent. <br />