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SWRCB, January 2006 <br />1 i r]X 1 1 1 <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: Tulare Farms, LLLP - ACE TOMATO I Date of Testing: 1-25-2013 <br />Facility Address: 2771 E FRENCH CAMP RD FRENCH CAMP CA <br />Facility Contact: MIKE Phone: <br />Date Local Agency Was Notified of Testing :1-8-13 <br />Name of Local Agency Inspector (f present during testing): MUNI <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 d 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: h20 and tape measure Equipment Resolution: 1/16 <br />1 87 <br />2 DSL 3 <br />4 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />Bucket Installation Type: <br />® Direct Bury <br />❑Contained in Sump <br />❑ Direct Bury <br />®Direct Bury <br />El Contained in <br />❑Contained in Sump Sump <br />❑ Direct Bury <br />El Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 11 <br />Bucket Depth: <br />13.75 <br />13.75 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />10 <br />10 <br />Initial Reading (RI): <br />13 <br />13 <br />Test End Time (TF): <br />11 <br />I 1 <br />Final Reading (RF): <br />13 <br />13 <br />Test Duration (TF — Ti): <br />IHR <br />IHR IHR <br />Change in Reading (RF - Rr): <br />0 <br />0 0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 1/16 <br />Test Result: '', <br />Z Pass ❑ Fail <br />® Pass ❑ Fail ❑ Pass ❑ Fail <br />❑ Pass L] Fail <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 1-25-2013 <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 />