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08/29/2008 11:06 FAX X1007/008 <br /> Spill &racket `i enfing Repotri Foam <br /> This Jbrm is intendedfor use by cuntruclots perfbrming antrual testing of 11S'Ts7;ill c,.tainment structures. 71te coinpleted f,rm a"?d <br /> printouts_f-um tests(if applicable),should be provided to the facility oivner/uperalor fbr submittal to the local regflatw y agencT. <br /> _ 1. FACILITY INFORMATION <br /> Facility Namu: -.�_$ l.)ate of'I'esting: —1.90 <br /> Fucilil Address <br /> Facility Contact' - <br /> Date Local AgencyisVl7 Notified ol-Testing: <br /> Name of Local Agency Inspector(ij'pr(-,senl during lesling): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST -416 2""Street Galt,CA 95632 (209)744-01 12 Fax--(209)744-0i 16 <br /> Technician Conducting Test. ❑ Lyle t). Nimmo ❑ 7.anc A,Nitnmo ® David A_Winkler ❑ Felix G. Ramirez <br /> 5249115-IJT 5263322-UT 5263373-IJT 5273931-UT <br /> Credentials: i] ICC:Service Tach_ .0 SWRCR Tank'rester <br /> •-1735._, --• -- •• . ...,. <br /> 3.STILL BUCKET TE,STING INFORMATION <br /> Test Method Used: Hydrostatic ❑vacuum Other <br /> Test Equipment CJsed: _ Equipment Resolution: <br /> Identify Spill Bucket(By Tank I Z 3 4_T -- <br /> Number, Stured Product, etc) <br /> Bucket Installation Type. ® Direct Bury R1 Direct Bury <br /> Direct Bury (_]Direct Rory <br /> ❑Contained in Swnp ElContained inSump El contained in n Contained in j <br /> _ Sum tiurrtp <br /> ` Bucket Diameter: " <br /> Bucket Depth: <br /> Wait time between applying -- <br /> vacuum/water and start of test: <br /> Test S4-►rt'Time(Tr): 13TU <br /> Initial Keading(R,): !3 <br /> 'fest End TimC(Tr,): <br /> Final Reading(R,:); <br /> Test Duration('I F-Tr): Al- <br /> Change <br /> inReading(R,-RI); <br /> — <br /> I'ass/fail'Threshold or <br /> Criteria: <br /> Test Result: - Pass ❑ Fail Pass ❑Fall Pass ❑Fail ❑:Pam ❑Fail <br /> COMMCntS—(inc/rtde inform.!",.un repairs made prior to testing, and reyommended follow-up for failed tests) <br /> . I <br /> CERTIFICATION OF TECHI ICIAN RFS NSIBL)E FOR CONDUCI-ING THIS TESTING <br /> I hereby certify that all the informati w ontained i this report is true,accurate,and In full compliance with legal mquireurcnts_ ! <br /> Technician's Signature: Date: ) <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.Ilowever, local requirements <br /> may be more stringent. <br />