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4 <br />Ll <br />1�1 <br />Spill But Testing Report Foral January 200f) <br />cke <br />This firm is intended for use by contractors Performing annual testing of UST spill containatenI structures. The coinpletedft)f-In and <br />Prirtfoutsftom tests (ifa[,p1icri,h1c), should beprovided to the facility ott)ner-lo,,,,eratoi-,for stibit-.?iii6rlio t,-,telocal regulatory , arc n" --y. <br />1. FACILITY INFORMATION <br />Facility Narrie:�l(,Qn-v' r,�-Date of Testing: <br />Facility Address: bl el - <br />CA, C"i -4- <br />Facility Contact: Phone: ( Z(y=j) <br />Date Local Agency Was Notified of Testing: 0 <br />Name of Local Agency Inspector (ii(present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2 "d Street Gait, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: El Lyle D. Nimmo 0 Zane A. Nimmo El David A. Winider Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': ICC Service Tech. T1SWRCB Tank Tester <br />'A QW11 I IDTTd,171V•V rv-VL1m- <br />Test Method Used: Hydrostatic EVacuum ❑ Other <br />Test Equipment Used: L <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />I <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />Direct Bury <br />Contained in Sump <br />E[Direct Bury <br />El Contained in Sump <br />EEJ Direct Bury <br />] Contained <br />FE] Contained in <br />Suninp <br />D <br />ury <br />❑Direct Bury <br />El Contained in <br />Bucket Diameter: <br />-.Sump <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TI): <br />Initial Reading (RI): <br />Test End Time (TF): <br />Final Reading (RF): <br />/ 72- <br />Test Duration (TF — Tj): <br />V1 0 U <br />Change in Reading (RF - RI): <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result <br />LPass El Fail <br />Pass 7 <br />Pass 'E1 Fail <br />11 Pass El Fail] <br />-- jlff{ $"(4U JrYUrff(E4jtUrj Uri <br />75 6 T-) 2 l',J(- J A ') A t <br />D r -) (- g � <br />faae prior to testing, and recommended <br />W, <br />CERTIFICATION OF TECHNICIAN N RESPONSIBLE FOR COND11VTING THIS TESTING <br />I hereby certify that all the i fortnaflo,7con-'ta'ine d in this reporf is e, accurate, and in full compliance with legal requirements. <br />in <br />Technician's Signature: IR Date: C) C) K) <br />State laws and regulation d not currently require test4to_b performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />