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SWRCB, January 2006 <br />Spill Bucket Testing Report 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 tam rif applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br />1. FAC HATY INFORMATION <br />Facility Name: F I Z:- -�C_ p Qr Date of Testing: 6-0-01 <br />Facility Address: elitlo ?ft4jfr1C- 166 2c?7f <br />Facility Contact. C1 elf& Phone: -70,01 42S- 05C)!2 <br />Date Local Agency Was Notified of Testing: <br />[—Na—me of Local Agency Inspector,(afpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDATEST 416 Td Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test ❑ Lyle D. Nimmo f;-kl Zane A. Nimm E] David A. Winkler E] Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': g] ICC Service Tech. [21 SWRCB Tank Tester <br />3. SP HL BUCKET TESTING INFORMATION <br />Test Method Used: FKI Hydrostatic ❑ Vacuum Lj Other Of <br />Test Equipment Used: 2p—c 1 Equipment Resolution: <br />I Bucket Iristallation T3W: <br />■a 0.7 F, T <br />r1D6 MY■Direct <br />Direct Bury in <br />Contained in sump El Contained <br />S latrSUMP <br />Bury <br />an <br />Contied in i <br />Bucket Diameter. <br />wom <br />7 141; <br />