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SWRCB, January 2006 <br />Spill g Renort Form <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 />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 ❑ David A. Winkler ® Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <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 />Identify Spill Bucket (By Tank 1 87 <br />Number, Stored Product, <br />2 91 <br />3 DIE <br />4 <br />Bucket Installation T ® Direct Bury <br />YPe: <br />❑Contained in Sump <br />® Direct Bury <br />El Contained in Sump <br />® Direct Bury <br />El Contained in <br />Sump <br />❑ Direct Bury <br />El Contained in <br />Sum <br />Diameter: 11 <br />i l <br />11 <br />[Bucket <br />ucket Depth: 141/2 <br />141/2 <br />14 <br />ait time between applyingacuum/water and start of test: <br />- <br />- <br />Test Start Time (Ti): 1230 <br />1230 <br />1230 <br />Initial Reading (Rj): 141/2 <br />141/2 <br />14 <br />Test End Time (TF): 1330 <br />1330 <br />1330 <br />Final Reading (RF): 141/2 <br />141/2 <br />14 <br />Test Duration (TF — TI): 1 HOUR <br />1 HOUR <br />i HOUR <br />Change in Reading (RF - RI): 0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: - <br />- <br />- <br />Test Result: ® Pass ❑ Fail <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />®PW 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:#f� <br />Date:07-27-12 <br />1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />