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0 0 SWRCB, January 2006 <br /> Spill Bucket Testing Report Form <br /> This forma 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 /> 1. FACILITY INFORMATION <br /> Facility Name: LATHROP GAS AND FOOD I I Date of Testing: 12-02-09 <br /> Facility Address: 14800 WEST FRONTAGE ROAD LATHROP CALIFORNIA 95336 <br /> Facility Contact: JESSIE Phone: 209-239-2717 <br /> Date Local Agency Was Notified of Testing:l 1-10-09 <br /> Name of Local Agency Inspector(ffpresent during testing): SAN JOAQUIN CO TWIE AND MOONEY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"d Street Galt, CA 95632 (209) 744-0 1 12 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': Z ICC Service Tech, ® SWRCB Tank 'fester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> 'fest Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: TAPE H2O Equipment Resolution: 1116 <br /> Identify Spill Bucket (By Tank 1 87 2 91 3 DIE 4 <br /> Number, Stored Product, etc.) <br /> Z Direct Bury Z Direct Bury ® Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: [:1 Contained in ❑ Contained in <br /> ❑ Contained in Sump E] Contained in Sump Sump Sum <br /> Bucket Diameter: l 1 11 I 1 <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: - <br /> Test Start Time(Ti): 900 900 <br /> Initial Reading(Ra): 12 12 112 <br /> Test End Time(TF): 1000 1000 <br /> Final Reading(RF): 12 12 1/2 - <br /> Test Duration(TF—Ti): I HOUR I HOUR <br /> Change in Reading(Rr-Rc): 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail Z Pass ❑ Fail ❑ Pass ® Fail ❑ Pass [:] Fail <br /> Comments— (include information on repairs made prior to testing, and i,ecoraararended follow-tip for•failed tests) <br /> (,10,Ved DRAIN AND DROP TUBE , BUT DIESEL SPILL BUCKET STILL FAILED. <br /> Contractor will repair and retest <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: 12-2-09 <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 />