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SWRCB,January 2006 <br /> 9. SO Bucket Testing epor or <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: KAISER MANTECA Date of Testing: 08/13/2010 <br /> Facility Address: 1777 W YOSEMITE AVE , MANTECA, CA, 95337 <br /> Facility Contact: PAUL ST. ONGE Phone: (2 0 9) 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 : E CSLB Contractor o ICC Service Tech. ❑SWRCB Tank Tester ❑X Other(Specify) CONTRACTOR <br /> License Number: 743160 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: xl Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used:TAPE MEASURE Equipment Resolution:1/16 " <br /> Identify Spill Bucket(By Tank 1 I DIE FILL 2 3 4 <br /> Number, Stored Product, etc) <br /> Bucket Installation Type: ❑X Direct Bury E]Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑ Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 11 <br /> Bucket Depth: 12 <br /> Wait time between applying 5MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 0 915 <br /> Initial Reading(RI ): 11.125 <br /> Test End Time(TF ): 1015 <br /> Final Reading(R F ): 11.125 <br /> Test Duration: 1HR <br /> Change in Reading(R F-RI ): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <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: 08/13/2010 <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />