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2098253893 ENGINEERING DEPT. 0 :58 a.m. 09-10-2010 17/21 <br /> SWRCB,January 2006 <br /> 9. Spill Backet Testing Report Form <br /> This form is intended for use by contractors performi g 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: KAISER MANTECA Date of Testing: 08/13/2010 <br /> Facility Address: 1777 W YOSEMITE AVE TECA, CA, 95337 <br /> Facility Contact: ENGINEERING MANAGER Phone: (2 0 9) 825-3460 <br /> Date Local Agency Was Notified of Testing: 0 7/2 7/e2 010 <br /> Name of Local Agency Inspector(if present during testing): NA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY„ INC. <br /> Technician Conducting Test: ` KELVIN CRUZ <br /> Credentials]:E CSLB Contractor D ICC Service Tech. ❑SWRCB Tank Tester 1fl Other(Spec) CONTRACTOR <br /> License Number: 743160 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic ❑ Vacuum F-1 Other <br /> Test Equipment Used:TARE MEASURE Equipment Resolution:1/16 " <br /> Identify Spill Bucket By Tank 1 1 DIE FILL 2 3 4 <br /> Number,Stored Product,etc.) <br /> QXContai d in Sum Contained in Sum ❑Contained in Sum ❑Contained in Sump <br /> Direct ury ❑Direct Bury [�Direct Bury ®Direct Bury <br /> / Bucket Installation Type: ® p p p <br /> Bucket Diameter: 11 <br /> Bucket Depth: 12 <br /> Wait time between applying <br /> SMIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 0915 <br /> Initial Reading(RI ): 11.125 <br /> Test End Time(TF): 1015 <br /> Final Reading F ): 11.12 5 <br /> Test Duration: 1HR -- <br /> Change in Reading(R F—Rr ): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Elm <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 /> Techniciap's Signature: Date: 08%13/2010 <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 />