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I <br /> SWRCEI,.las�t�a�y 2006% 0 0 <br /> Spill Bucket `Westin Ort ori <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The con-pleted forth and <br /> printouts from tests(if applicable), should be provided t he facility owner/operator for submittal to the local regulatory agency. <br /> _ 1.FACILITY INFORMATION <br /> Facility Name: Od l Date of Testing: 1070- AAg6 <br /> Facility AddressM 0 Yyf qV /— lT i <br /> Facility Contact: GYAPhone:c Z v�> <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector.(fpresent during testing): MUw1� <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.Winkle Felix G. Ramirez - <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': CC Service Tech. OSWRCB Tank Tester <br /> 3.SPILL,BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used Y-vp 2 D Equipment Resolution: eb <br /> Identify Spill Bucket(By Tank I -D-L F 2 3 4 <br /> Number,Stored Product, etc. <br /> Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑Contained in ❑Contained in <br /> ❑Contained in Sump ❑Contained in Sump <br /> Sump Sum <br /> Bucket Diameter: I <br /> Bucket Depth: l <br /> Wait time between applying <br /> vacuum/water and start of test: jCJ <br /> Test Start Time(T1): l b <br /> Initial Reading(RI): <br /> Test End Time(TF): u b <br /> Final Reading(RF): — <br /> Test Duration(TF—Tj): <br /> Change in Reading(RF-RI): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result. ; ❑ Pass Fail ❑ Pass' .❑Fail ❑ Pass ❑Fail El ; ❑Fail ` <br /> Comments—(include information on re a's de prior to testing, and recommended follow-up or failed tests) <br /> CERTIFICATION OF TE ICIAN RESPONSIBLE FOIL CONDUCTING Wfi][S TESTING <br /> I hereby certify that all the i or tin contained in is report is Mue,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 1 0b) 3110p, <br /> ' State laws and regulat' s do not currently require testinto be rmed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />