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. . 6 <br />SWRCB, January 2006 <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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: SUTTER TRACY Date of Testing: 11-29-2011 <br />Facility Address: 1420 N TRACY BLVD TRACY C A <br />Facility Contact: STEVEN Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (f present during testing): TWI <br />2. TESTING 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. 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 <br />Identify Spill Bucket (By Tank 1 DSL 2 <br />Number, Stored Product, etc. <br />Equipment Resolution: 1/16 <br />3 4 <br />Bucket Installation Type: ® Direct Bury <br />El Contained in Sump <br />❑ Direct Bury <br />El Contained in Sump <br />❑ Direct Bury <br />❑ Contained in <br />SUM2 <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: 11 <br />Bucket Depth: 10 <br />Wait time between applying <br />vacuum/water and start of test: <br />- <br />Test Start Time (Ti): 230 <br />Initial Reading (Ri): 9 <br />Test End Time (TF): 330 <br />Final Reading (RF): 9 <br />Test Duration (TF — TI): IHR <br />Change in Reading (RF - RI): 0 <br />Pass/Fail Threshold or 1/16 <br />Criteria: <br />Test Result: ®'Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass E3 Fail <br />❑ Pass ; ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <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 11-29-2011 <br />1 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 />