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® From: Franzen -Hill Inc. To: 12094683433 Page: 3/6 Date: 4/18/2011 9:57:58 AM <br />0 <br />SWRCB, January 2006 <br />Spill Bucket TestingOri Form <br />Phis 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 tine facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: LATHROP SHELL Date of Testing: 02/07/11 <br />Facility Address:16500 S HARLAN <br />Facility Contact: NICK Phone: 209-403-3859 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): TIIEUY IRAN <br />Company Name: .Franzen -Hill <br />Technician Conducting Test: Steve 7wahlen <br />Credentials': X CSLB Contractor X ICC Service Tech. 0 SWRCB Tank Tester 0 Other (Specify) <br />License Number(s): A304147 — 5254508 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: X Hydrostatic 0 Vacuum 0 Other <br />Test Equipment Used: Equipment Resolution: .0 1 <br />Identify Spill Bucket (By Tank 1 87 - gasoline <br />Number, Stored Product, etc) <br />2 91- gasoline 3 <br />4 <br />Bucket Installation Type: X Direct Bury <br />0 Contained in Sump <br />X Direct Bury 0 Direct Bury <br />0 Contained in Sump 0 Contained in Sump <br />0 Direct Bury <br />Q Contained in Sum <br />Bucket Diameter: 10"-___....._ <br />10" <br />Bucket Depth: 14" <br />14.25" <br />Wait time between applying 10 min <br />vacuum/water and start of test: <br />lomin <br />Test Start Time (Tr): 10:00 am <br />10:30 am <br />Initial Reading (RT): 13.50 <br />13.75 <br />Test End Tune (TF): 11:00 am <br />11:00 am <br />Final Reading (RF): 13.50 <br />13.75 <br />Test Duration (Tr — T�: 60 min <br />60 min <br />Change in Reading (RF -Rr): 0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: X ]Pass 0 Fail <br />X Pass O.Fa 0 Pass 0 Fail <br />0. Pass 0 Fail <br />Coniments — (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 informa&n contained in this report is truce, accurate, and in, full compliance ivith legal requirements. <br />Technician's Signature: _Steve Zwahlen / <br />Date: 217/1 <br />1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />This fax was sent with GFI FAXmaker fax server. For more information, visit: http://www.gfi.com <br />