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v <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 />Facility Name: VERIZON-MANTECA CO Date of Testing: October 01, 2008 <br />Facility Address: 460 W. CENTER ST. <br />Facility Contact: MASOOD CHOUDHURY Phone: 909-337-0000 <br />Date Local Agency Was Notified of Testing: October 01, 2008 <br />Name of Local Agency Ins ector fftpresent during testin : MUNIAPPA NAIDU <br />Company Name: SUNWEST ENGINEERING <br />Technician Conducting Test: RUDY ALMAZAN <br />Credentials : CSLB Contractor❑ ICC Service Tech. SWRCB Tank Tester Other (Specify) <br />License Number(s): 5256842 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: HYDROSTATIC <br />Test Equipment Used: WATER <br />�s9. rti��.t. ,� -��,r yvrs �.... ws "..r�o�x „ rte. n. n3n irzi e. .. ,rr.r rnrau.,.,, <br />r � .<.-�� z a.. -✓�,r ,�,ow,,.,. <br />��ai�E. xnw w.� r « ��r..-. ia.w� <br />i uniircn�m s,�.�.-.. __ <br />Identify Spill Bucket (by Tank I DIESEL <br />Number, Stored Product, etc. <br />2 <br />3 <br />4 <br />Bucket Installation Type: ❑Direct Bury <br />Contained in Sump <br />❑Direct Bury <br />Contained in Sump <br />❑Direct Bury <br />Contained in Sump <br />❑Direct Bury <br />Contained in Sump <br />Bucket Diameter: 10 1/2" <br />Bucket Depth: 10 1/2" <br />Wait time between applying 15 MIN. <br />vacuum/water and start of test: <br />Test Start Time (Ti)- 1:00 PM <br />Initial Reading (Rj 7" <br />Test End Time (TF): 1:30 PM <br />Final Reading (RF): 7" <br />Test Duration (TF - TI): 30 MIN. <br />Change in Reading (RF- RI): 0" <br />Pass/Fail Threshold or 0.002 <br />Criteria: <br />_, <br />P <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: <br />D, October 1 1, 2008 <br />1 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 />