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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[IST spill containment structures. The completed farm and <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: LATHROP FOOD GAS I Date of Testing: 12-27-2011 <br /> Facility Address: 14800 FRONTAGE RD MANTECA CA <br /> Facility Contact: JESSIE Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Locai Agency Inspector(if present during testing): ARIS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2" Street Galt,CA 95632 (209) 744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ❑ Zane A.Nimmo Z David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: N ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ vacuum ❑ Other <br /> Test Equipment Used: h20 and tape measure Equipment Resolution: 1116 <br /> Identify Sprll Bucket (13v Tank 1 91 2 87 3 DSL 4 <br /> Number, Stored Product, etcJ <br /> ®Direct Bury ®Direct Bury ® Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ❑Contained in ❑ Contained in <br /> Contained in Sump ❑Contained in Sump Sum Sum <br /> Bucket Diameter: 11 ]I 11 <br /> Bucket Depth: 14 13 13 <br /> Wait time between applying _- -_ <br /> vacuum/water and start of test: <br /> Test Start Time(Tt): 9 9 9 <br /> Initial Reading(Rt): 13 12 12 <br /> Test End Time(TF): 10 10 10 <br /> Final Reading(RF): 13 7 12 <br /> Test Duration(TF—TI): 1 HR I HR 1 HR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or 11161116 1116 <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ❑ Pass ® Fail I Z Pass ❑Fail ❑ Pass ❑ Fail <br /> Com menu (include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> 8—BUCKET FAILED . THINK IT IS THE DRAIN . ELITE WILL FIX ASAP _ <br /> CLRTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> hereby certifp that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date 1.2-27-2011 <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 />