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v <br />0 SWRCB, January 2006 <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 />1. FACILITY INFORMATION <br />Facility Name: COUNTRY CLUB 76 1 Date of Testing: 1-15-13 <br />Facility Address: 2575 COUNTRY CLUB BLVD STOCKTON CA <br />Facility Contact: NICK Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (fpresent during testing): SAN JOAQUIN CO GARRETT <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA 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. ® SWRCB Tank Tester II <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used TAPE / H2O <br />Equipment Resolution 1/16 <br />r.... ...... .F ...... ,. ....:.... , ,,... ,,,,.. <br />Identify Spill Bucket (By Tank 1 87 <br />Number, Stored Product, etc.) <br />2 91 <br />3 DIE <br />4 <br />Bucket Installation Type: ❑Direct Bury <br />® Contained in Sump <br />Direct Bury <br />® Contained in Sump <br />F] Direct Bury <br />® Contained in <br />SumpSum <br />❑ Direct Bury <br />❑ Contained in <br />Bucket Diameter: 11 <br />11 <br />11 <br />Bucket Depth: 13 <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />Test Start Time (TI): 1200 <br />1200 <br />1200 <br />Initial Reading (RI): 13 <br />13 <br />13 <br />Test End Time (TF): 1300 <br />1300 <br />1300 <br />Final Reading (RF): 13 <br />13 <br />13 <br />Test Duration (TF — TI): 1 HOUR <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - RI): 0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result; <br />® <br />Pass <br />❑ <br />Fail <br />0 <br />Pass ❑ Fail <br />® Pass <br />[I <br />Fail <br />❑ Pass [:]Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />PHIL TITS 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: Date:01-15-13 <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 />