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RECEIVED <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form JAN 0 2 2013 <br /> This form is intended for use by contractors performing annual testing of UST spill cots meat structures. The complete form and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator�s�urr' � �cf� t � agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: LATHROP GAS AND FOOD Date of Testing: 12-11-17 <br /> Facility Address: 140 E LATHROP RD LATHROP CA 95330 <br /> Facility Contact: JESSIE Phone: 209-814-3730 <br /> Date Local Agency Was Notified of Testing A 1-22-17 <br /> Name of Local Agency Inspector(if present during testing): SAN JOAQUIN CO BETTY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA'PEST 416 2"d Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Ed Sterns ❑ Zane A.Nimmo ❑ David A.Winkler ® Felix G. Ramirez <br /> 814188-UT 8211269-UT 5263373-UT 527393A UL'I-- - <br /> Credentials': [3 ICC Service Tech. ❑ SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: TAPE/H20 Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIESEL 4 <br /> Number, Stored Product, etc.) <br /> ❑ Direct Bury E] Direct Bury <br /> Bucket Installation Type: ® Direct Bury Direct Bury ❑ Contained in ❑Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump Sump Sum <br /> Bucket Diameter: 1 I 11 l I <br /> Bucket Depth: 15 15 15 <br /> Wait time between applying - <br /> vacuum/water and start of test: <br /> Test Start Time(Tl): 900 900 900 <br /> Initial Reading(Ri): 14 14 14 <br /> Test End Time(TF): 1000 1000 1000 <br /> Final Reading(RF): 14 14 14 <br /> Test Duration(TF—Ti): I HOUR I HOUR I HOUR <br /> Change in Reading(RF-R,): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail E Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up fr)r.failed tests) <br /> OPW BUCKETS <br /> ALL BUCKETS FOLD 5 GALLONS <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:12-11-17 <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 />