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Spill Becket Testing Report o r <br />This form is intended for use hV contractors perforn ing annual testi?ag of UST spill conlainrraenl st au°turrs. The c,nra,,plen,.Jjbrnn arul <br />pa•intouts fton2 tests (f applicable), should be provided1 the facility o�w?er/operator fo, .,u'urraival to the local regarlatopj, crgc,,z<,y. <br />Facility Name: G� , -- - - - Date of Testing n - 1- p <br />Facility Address: Z <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (rf •present during testing): <br />E <br />2. TESTfNG C ONTR A CTn2 MMUM A T-9n1r <br />Company Name: AFF® A 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 />I Credentials': ICC Service Tech. Ej•SWRCB Tank Tester <br />3_ SPH,11".1{ TTf'1lZI .TiNTn-DAmId-17V <br />Test Method Used: nHydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: 1 �jp7 -Z Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 <br />2 g 3 <br />1 <br />4 <br />Bucket Installation Type: <br />Direct Bury <br />MContained in Sump <br />Direct Bury ❑ Direct Bury <br />Contained in Sump El Contained in <br />Sum <br />❑Direct Bury <br />❑ Contained in <br />Sum. <br />Bucket Diameter: <br />t <br />Bucket Depth: <br />1 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />Initial Reading (RI): <br />.17019 <br />f q <br />Test End Time (TF): <br />loop <br />l000 <br />Final Reading (RF): <br />12 V <br />Test Duration (TF - TI): <br />Change in Reading (RF - RO: <br />Pass/Fail Threshold or <br />Criteria: <br />- <br />Test Result <br />Pass Fail <br />Pas ❑ Fail ❑Pass ❑Fail <br />❑Pass .; ❑Fail ` <br />a,v,ua8xa unw,a - (incruae rn u atiM on reparrs maae prtor to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONI9[Ji`,"fiNG THIS TESTING <br />I hereby certify that all the informatio!-PatOffined in this report is&ue, accurate, and in full compliance with legal requirements. <br />Technician's Signature: <br />' State laws and regulations do not currently require testing to be performe ua ified contractor. However, local requirements <br />may be more stringent. <br />