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REG ^ 2006 <br /> Spill Bucket Testing Report Form JAN 11 ?0« <br /> This form is intendedfor 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� g st ?y agbncy. <br /> .�no•rs Erna-r^u e-_ _ <br /> 1. FACILITY INFORMATION <br /> Facility Name: LATHROP GAS&FOOD I Date of Testing: 12/9/2015 <br /> Facility Address: 140 E. LATHROP RD. LATHROP, CA 95330 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing :1 1/19/2015 <br /> Name of Local Agency Inspector(if present during testing): STACY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFOR.DA TEST 4162 nd Street Gait,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo F� Zane A.Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ® ICG Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> r Bucket Installation Type- � Direct B ® Direct Bury � Direct Bury <br /> yp Bury ❑ Direct Bury <br /> ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in ❑ Contained in <br /> Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 14 1/4 13 1/2 14 1/4 <br /> Wait time between applying <br /> vacuum/water and start of test: -- -- <br /> Test Start Time(TI): 0920 0920 0920 <br /> Initial Reading(Rj): 13 1/4 12 1/2 13 1/4 <br /> Test End Time(TF): 1020 1020 1020 <br /> Final Reading(RF): 13 1/4 12 1/2 13 1/4 <br /> Test Duration(TF--Tj): HR HR HR HR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: -- -- __ <br /> Test Result. JZ::Pas$ :.;❑.Fail ❑ Pass ❑Fail E Pass ❑Fail I N. Pass [:]Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <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 Date: <br /> 1 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 />