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4 �t • 0 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Farm <br /> This farm 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 owner/operator for submittal to the local regulatory agency, <br /> 1. FACILITY INFORMATION <br /> Facility Name: LATI IROP FOOD GAS Date of Testing: 12-20-10 <br /> Facility Address: 14800 FRONTAGE RD MANTECA CA <br /> Facility Contact: JESSIE Phone: <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(ifpresent during testing): MOONY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209)744-0112 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 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 Spill Bucket (By Tank 1 87 2 91 3 DSL 4 <br /> Number, Stored Product, etc. <br /> M Direct Bury ® Direct Bury ® Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: E] Contained in El Contained in <br /> El Contained in Sump ❑ Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 12.50 14 14 — <br /> Wait time between applying <br /> vacuum/water and start of test: - - -- <br /> Test Start Time(Tj): 830 830 830 <br /> Initial Reading(R'): 11.75 13.75 12.50 <br /> Test End Time(TF): 930 930 930 <br /> Final Reading(RF): 11.75 13.75 12.50 <br /> Test Duration(TF—Ti): IHR IHR IHR <br /> Change in Reading(RF-Rt): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1116 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ❑ Pass 0 Fail ❑ Pass ❑ Fail ❑ Pass 0 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 /> "T'echnician's Signature: T&--j Date 12-20-2010 <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 />