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SWRCB, January 2006 <br />1 1 le � 1111111111111 111111 <br />1 # 11 <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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />Facility Name: Gas Depot 2 1Date of Testing: 08/17/2011 <br />Facility Address: 1330 E. Yosemite Ave. Manteca, Ca. 95336 <br />Facility Contact: Kevin Phone: (209) 825-0332 <br />Date Local Agency Was Notified of Testing : p/j- /8, // <br />Name of Local Agency Inspector (ifpresent during testing): Muniappa Naidu <br />3. SPILL BUCKET M1X1 *►, 6 <br />Test Method Used: xHydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Standard Tape Measure Equipment Resolution: N/A <br />Identify Spill Bucket (By Tank 1 T1: 87 Fill <br />Number, Stored Product, etc. <br />2 T2: 91 Fill 3 T3. Diesel Fill <br />4 T4: <br />Bucket Installation Type: Direct Bury <br />x Contained in Sum <br />mp <br />Direct Bury Direct Bury <br />x Contained in S!�np x Contained in Sump <br />Direct Bury <br />Contained in Sum <br />Bucket Diameter: 12" <br />12" 12" <br />Bucket Depth: 133/4" <br />131/2" 17 VV <br />Wait time between applying 1 minute <br />vacuum/water and start of test: <br />1 minute 1 minute <br />Test Start Time (Ti): 1:27 p.m. <br />1:27 p.m. 1:27 p.m. <br />Initial Reading (RI): 121/<" <br />12" 15" <br />Test End Time (TF): 2:27 p.m. <br />2:27 p.m. 2:27 p.m. <br />Final Reading (RF): 12 'W' <br />12" 15" <br />Test Duration (TF- TO: 1 hr <br />ihr 1 hr <br />Change in Reading (RF - RI): 0 <br />0 0 <br />Pass/Fail Threshold or 1/16" <br />Criteria: <br />Test Result: x Pass ❑Fail <br />z Pass 0 Fail x Pass ❑ Fail <br />Pass ❑ Fail <br />Comments - (include information on repairs made prior to testing and recommended follow-up for ailed tests) <br />Placed water from spill buckets test into a 55 eal HAZ drum. <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 />59, <br />Technician's Signature• ZDate 08/17/2011 <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 />