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RECEIVED SWRCB, January 2006 This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (f applicable), should be provided to the facility owner/operator for submitt - 41PALa 9 1. FACILITY INFORMATION DEPARTMENT 2 TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 4162 Ind Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez 5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: TAPE MEASURE, H2O x.,....... . _........,. Equipment Resolution: 1/16" Identify Spill Bucket (By Tank Number, Stored Product, etc. 1 2 3 4 DIESEL Bucket Installation Type: ❑ Direct Bury ❑Contained in Sump El Direct Bury ❑Contained in Sump El Direct Bury ❑ Contained in Sump ®Direct Bury E] Contained in Sum Bucket Diameter: 11 Bucket Depth: 12 1/2 Wait time between applying vacuum/water and start of test: _- _ _ _ Test Start Time (TI): 10 Initial Reading (Ri): 12 Test End Time (TF): 11 Final Reading (RF): 12 Test Duration (TF — T,): HR HR HR HR Change in Reading (RF - RI): 0 Pass/Fail Threshold or Criteria: Test Result: ❑ :Pass ❑ Fail; ❑ Pass ❑ Fail ❑ Pass ❑ Fail Z Pass ❑ Fail Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature Date: 11-21-14 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.