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SWIRCB,January 2006 <br /> SPHI Bale-;.et Testing Rb ®rt For <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 /> I. FACILITY INFORMATION <br /> [Facility Name:U,A� Date of Testing: E T <br /> Facility Address: �, d S t X.s� <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(f present during testing): r c. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2°�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': ICC Service Tech. WRCB Tank Tester _ <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: D3, lydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: 'rid ` ZO Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) 77==�q <br /> Direct Bury [�Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: <br /> El Contained in Sump ❑ Contained in Sump ❑ Contained in El Contained in <br /> Sum Sum Diameter: I <br /> Bucket Depth: l <br /> Wait time between applying <br /> vacuum/water and start of test: S� <br /> Test Start Time(TI): h� <br /> Initial Reading(RI): Z' z %z <br /> Test End Time(TF): <br /> Final Reading(RF): 1/7 <br /> Z <br /> Test Duration(TF—Ti): U,r <br /> Change in Reading(RF-Rj): r <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: L_X' ,P=ass�_E_ <br /> Fail t, ❑4,Pass< ❑ Fail ❑a[ElFailPass El Fail <br /> Comments—(include informatiN—uh s made prior to testing and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHN RESP NSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the informat' n containdd in this rejis ,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: v . <br /> Date: <br /> ' State laws and regulations do n cunreintly require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />