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' SWRCB, January 2006 <br />S uc et Testing Report AM <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. FACILI'T'Y INFORMATION <br />Facility Name: j -% Date of Testing: <br />Facility Address: <br />Facility Contact: Phone�.v - <br />Date Local Agency Was Notified of Testing: s _ <br />Name of Local Agency Inspector (if present during testing): <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 " avid A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': NICC Service Tech. E SWRCB Tank Tester <br />A CPYT.T. RATCWV..T TF..CTiNf- TNFORMAT10N <br />Test Method Used: ffHydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: �,� = jy! �" <br />Equipment Resolution: j` <br />Identify Spill Bucket (By Tank 1 <br />Number, Stored Product, etc. C > <br />2�( <br />3 <br />I / <br />4 <br />EJ -Direct Bury <br />Bucket Installation Type: El Contained in Sump <br />E -Direct Bury <br />El Contained in Sump <br />uect Bury <br />EJ Contained in <br />SumpSum <br />❑ Direct Bury <br />El Contained in <br />Bucket Diameter: <br />Bucket Depth: 3 <br />/ Z. <br />Z <br />Wait time between applying <br />vacuum/water and start of test: - <br />—` <br />Test Start Time (Ti): <br />`�•° <br />f .'` <br />Initial Reading (RI): f! <br />j <br />Test End Time (TF): /G, G -D <br />/ <br />Final Reading (RF):Z1 6 <br />3 <br />t t <br />Test Duration (TF - Ti): <br />Change in Reading (RF - Ri): <br />Pass/Fail Threshold or <br />Criteria: <br />`- <br />Test Result: OLrass ' ❑ Fail <br />ass" ❑ Fail <br />:Pass Ej Fail <br />❑ Pass ❑ Fail <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />/ &-5 l ismC/c/c-1 <br />1-11-10 � � •�� . ave C' -i <br />CERTIFICATION OF TEC r ICIA ESPONSIBLE FOR CONDUCTING THIS TES'T'ING <br />I hereby certify that all the eorm, ion contas e€1 in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: j^ Date: <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 />