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n <br />0 SWRCB, January 2006 <br />This form 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 />FacilityName: KAISER MANTECA Date of Testing: 08/13/2010 <br />Facility Address: 1777 W YOSEMITE AVE , MANTECA, CA, 95337 <br />Facility Contact: ENGINEERING MANAGER Phone: (209) 825-3460 <br />Date Local Agency Was Notified of Testing: 07/27/2010 <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 : <br />❑x <br />CSLB Contractor <br />� <br />ICC Service Tech. <br />11 <br />SWRCB Tank Tester <br />❑X <br />Other (Specify) CONTRACTOR <br />License Number: 743160 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />[:X] Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: TAPE MEASURE <br />Equipment Resolution: 1/16 " <br />Identify Spill Bucket(By Tank <br />Number, Stored Product, etc.) <br />i 1 DIE FILL <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />❑X Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />E]Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />11 <br />Bucket Depth: <br />12 <br />Wait time between applying <br />vacuum/water and starting test: <br />5MIN <br />Test Start Time (Ti ): <br />0915 <br />Initial Reading (Ri ): <br />11.125 <br />Test End Time (TF ): <br />1015 <br />Final Reading (RF ): <br />11.125 <br />Test Duration: <br />1HR <br />Change in Reading (R F - Ri ): <br />0 <br />Pass[Fail Threshold or <br />Criteria: <br />0 <br />Test Result: <br />Q Pass .❑ Fail <br />E] Pass E]Fall! <br />Pass 0 Fail <br />❑ Pass 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 />Technician's Signature: Date: <br />08/13/2010 <br />i 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 />