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2006SWRCB, January <br />S%1 Bu'cket Testing Report A M <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 ownerloperator for submittal to the local regulatory agency. <br />Facility Name: PAC -41(,`i Date of Testing: t <br />Facility Address: y (j%j' C C AVt- <br />Facility Contact: 1?1Phone: Z4� <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (rf present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 d Street Galt, CA 95632 1(209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo R David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': ICC Service Tech. 0 SWRCB Tank Tester I)C--1'7:?c <br />3. SPILL, BUCKET TESTING INFORMATION <br />Test Method Used: IffHydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: q7 <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank 1? <br />Number, Stored Product, etc. <br />2 F13 <br />4 <br />d Direct B <br />Bucket Installation Type: ❑' <br />❑Contained in Sump <br />Direct Bury <br />F1 Contained in Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sump <br />Direct Bury <br />❑Contained in <br />Sum <br />Bucket Diameter: i e <br />' r <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TI): <br />Initial Reading (Rj): <br />Test End Time (TF): f v L)o <br />j 0o v <br />Final Reading (RF): Ile <br />Test Duration (TF — TI): /k- <br />/1 <br />Change in Reading (RF - RI): <br />Pass/Fail Threshold or <br />Criteria:— <br />---- ---- <br />Test Result: ass I❑Fail <br />n Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass El :Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TEC I N RES NSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the informatio coni fined in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature:"" Date; P ` C' <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 />