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SWRCB, January 2006 <br />So Bucket Testing Report Fob <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br />printouts frorn tests (rf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />ri,rs �:: ►r =41 <br />Facility Name: -S l 64Z k24d Date of Testing: <br />Facility Address: 3 _?,y�5,� CA <br />Facility Contact: CArs Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector. (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 n1 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 d�. 17J5 <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: "Zp - TAX nne W -e,_ <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank 1 <br />Number, Stored Product, etc. �j <br />2 <br />91 <br />3 <br />b1'L <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury Contained in Sum <br />® p <br />ElDirect Bury <br />[] Contained in Sump <br />F] Direct Bury <br />® Contained in <br />Sump <br />❑Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: 1 Z <br />' L <br />I -L- <br />Bucket Depth: ► 7 <br />j y a z <br />j y <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TI): �: �p <br />c� - <br />9: 30 <br />Initial Reading (RI): /® <br />Test End Time (TF): <br />• <br />Final Reading (RF): 10 <br />I w <br />D <br />Test Duration (TF - TI): /-/g <br />yam, <br />Change in Reading (RF - RI): <br />Pass/Fail Threshold or <br />Criteria: -- <br />'— <br />�- <br />Test Result:;, Pass ' ❑Fail <br />Pass ❑ Fail ` <br />[ Pass ❑ Fail <br />❑Pass ❑ ail <br />Comments - (include information on repairs made prior to testing and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHNIC N PONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information onriined 'n this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: Date: 6-J6- r <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 />