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Sep 04 08 01 : 28p Rfforda Test (2091 744-011G p. 5 <br /> SWRCB..lanuary 2006 <br /> Spill Bucket 'Fasting Report Form <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 facilit),owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFO_RNIATION <br /> Facility Name: ;_ (� Date of Testing: —Q <br /> Facility Address: Z �f_ /p�ji (� �►G� (� <br /> Facility Contact: U j„ t Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): C� <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162"d 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: A ICC Service Tech. .0 SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: Zv ._ Equipment Resolution: <br /> Identify Spill Bucket(By Tank l 2 3 �� 4 <br /> Number, Stored Product, etc.) /7/ <br /> FE Direct Bury ® Direct Bury ® Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in ❑Contained in <br /> Sump Sum <br /> Bucket Diameter: <br /> Bucket Depth: T /`f <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): l 33U f 33U ►33 v <br /> Initial Reading(Rj): <br /> Test End Time(TF): /Y3 L) <br /> Final Reading(RF): R <br /> Test Duration(TF—T!): <br /> Change in Reading(RF-Ri): <br /> Pass/Fail Threshold or <br /> Criteria: —� <br /> Test Result: Pass ❑Fail Pass EIFail Pass ❑ Fail ElPass El Fail <br /> �42 <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TEC ICIAN Rtithis <br /> SIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the informati n"ontainreport is true,accurate,and in full compliance with legal requirements.! <br /> Technician's Signature: 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 />