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4CEIVELi <br />Spill Bucket Testing Report Form <br />ZQ'CB, January 2006 <br />6 <br />This form is intended for use by contractors performing annual testing of UST spill cont orm and <br />deted f <br />printouts from tests (if applicable), should be provided to the facility owner/operator forW�V=Qpstory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Country Club Valero I Date of Testing: 1-29-16 <br />Facility Address: 2575 COUNTRY CLUB BLVD STOCKTON CA 95204 <br />Facility Contact: DAVE HINDS Phone: 209-932-1307 <br />Date Local Agency Was Notified of Testing :12-30-15 <br />Name of Local Agency Inspector (f present during testing): FATIMA <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2nd 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': ® ICC Service Tech. ® SWRCB Tank Tester <br />z cnrr r uTTrUWT TF.CTiNf INFORMATION <br />Comments (include information on repairs made prior to testing and recommenaeajottow-up jor jauea sestLl <br />PHIL TITE BUCKETS <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature:. W�l Date:01-29-16 <br />' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, <br />local requirements may be more stringent. <br />