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N <br />v <br />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 & FUEL Date of Testing: 07-17-12 <br />Facility Address: 147 E LATHROP RD LATHROP CA 95330 <br />Facility Contact: GREG Phone: 209-858-2666 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector(if present during testing): SAN JOAQUIN CO. Thuy <br />2. TESTING CONTRACTOR INFORMATION <br />AFFORDA TEST 4162 nd 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 />Comments —(Include information on repairs made Prior to testing, ana recummursuGu -» <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />1 hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />, <br />Technician s Signature. Date:07-17-12 <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 />