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0 9 <br />SWR <br />Spill Bucket 'Fasting Report Form <br />® This form is intended for use by contractors performing annual testing of USTspill containment structures. The completedft and <br />printouts from, tests (if applicable), should be provided to the facility mvner/operator for subrnittal to the local regulatory agcs7i y. <br />__ _ _ 1. FACILITY INFORMATION <br />Facil ity Name: � G � � p Li _--- 2 Date of Testing: <br />Facility Address: g' A' <br />Facility Contact: Phone: <br />Date Local Agency Was N&fjed of Testing: <br />Name of Local Agency Inspector (Pf present during testing): <br />P. ) <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 G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT A 5273934 -UT <br />Credentials 1: CC Service Tech. WRCB Tank Tester <br />3. SPILL, BUCKET TESTING INFORMATION <br />Test Method Used: ydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used <br />Equipment Resolution:' Et <br />Identify pi Bucket (By Tank <br />Number, Stored Product, etc. <br />1 <br />g�9 <br />2,: <br />, ....:.. . <br />4 <br />Bucket Installation Type: <br />Bucket Diameter: <br />irect B <br />Bury <br />® Contained in Sump <br />j � <br />Direct B <br />„� �' <br />❑ Contained in Sump <br />� � <br />Direct Bury <br />ontained in <br />Sum <br />� <br />❑ Direct Bury <br />EJ Contained in <br />Sum <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test: <br />-� <br />1 0 1 cj <br />} O 1 <br />Test Start Time (Tj): 1015 <br />Initial Reading (Rj): <br />Test End Time (TF): \ <br />Final Reading (RF): <br />, 9 t/ <br />EKE <br />E] PAS ' ail <br />; <br />Pas ❑Fail <br />Test Duration (TF — TI): <br />Change in Reading (RF - RI): <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: Pass : ❑Fail , <br />f nnamp�.tc <br />ElPass . [IFail <br />- -I --• •-••�• • — , —. - ...uuG t r cvr 10sesnng, aita-re'comme ed follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TIIIS'i'ESTING <br />I hereby certify that all the infor ation contained in this report is fie, accurate, and in full compliance with legal requirements. <br />Technician's Signature: - - - <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 />