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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 (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 VALERO I Date of Testing: 07-08-10 <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 (fpresent during testing): SAN JOAQUIN CO. TWEE WEE <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: 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 E Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />II Credentials': E ICC Service Tech. E SWRCB Tank Tester 1I <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: E Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O Equipment Resolution: 1/16 <br />,,. , <br />"... <br />.s7 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 <br />2 91 3 DIE <br />4 <br />Bucket Installation Type: <br />E Direct Bury <br />El Contained in Sump <br />E Direct Bury <br />E Direct Bury El Contained in <br />El Contained in Sump Sump <br />El Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 11 <br />Bucket Depth: <br />13 <br />13 13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Tj): <br />1000 <br />1000 1000 <br />Initial Reading (Rj): <br />12 <br />12 12 <br />Test End Time (TF): <br />1100 <br />1100 1100 <br />Final Reading (RF): <br />10 <br />12 12 <br />Test Duration (TF— TI): <br />I HOUR <br />1 HOUR 1 HOUR <br />Change in Reading (RF - RI): <br />2 <br />0 0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 1/16 <br />Test Result: <br />❑ Pass Z Fail <br />Pass <br />❑ Fail E Pass ❑ Fail <br />❑ <br />Pass []Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />SPENT I HOUR TRYING TO FIX BUCKET. DRAIN AND DROP <br />TUBE ASSEMBLY. ELITE 4 IS GOING TO REPAIR & RETEST. <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:7-8-10 <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 />