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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <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 /> 1. FACILITY INFORMATION <br /> Facility Name: TWO GUYS FOOD AND FUEL Date of Testing: 7/16/13 <br /> Facility Address: 147 E.LATHROP RD. LATHROP, CA 95330 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:6/19/13 <br /> Name of Local Agency Inspector(if present during testing): Thuy <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ® Zane A.Nimmo ❑ David A. Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑ Vacuum ❑Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 3 91 4 DIESEL <br /> Number, Stored Product, etc.) <br /> ® Direct Bury ® Direct Bury <br /> Bucket Installation Type: ® Direct Bury ❑Direct Bury E]Contained in El Contained in <br /> F1 Contained in Sump ❑Contained in Sump Sump Sum <br /> Bucket Diameter: i l 11 11 <br /> Bucket Depth. 14 3/4 12 13 1/4 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 0910 0910 0910 <br /> Initial Reading(RI): 11 13 3/4 11- 12 1/4 <br /> Test End Time(TF): 1010 1010 1010 <br /> Final Reading(RF): 13 3/4 2- 12 1/4 <br /> Test Duration(TF—TI): HR HR HR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: - <br /> Test Result: ® Pass ❑ Fair ❑ Pass ❑Fail I ❑ Pass ®Fail ® Pass [:]Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> 91 Spill to be repaired and retested by Elite IV <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 4L °�' Date: 7-16-13 <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 />