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S WRCB, January 2006 Tl:is form is intended, for use by contractors perforniing annual testing of UST spill containment structures. Tlie completed form and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION 2. TF,STTNG CONTRACTOR INFORMATION Company Name: ELITE IV CONTRACTORS Technician Conducting Test: 2CC /,t l/1c1G�1 Credentialsl: CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other (Specify) License Number(s): j(ie t t t?? J,? i�etic), 3. �PTf ,T, RTICKF.T TF,STIN<Y INFORMATION Test Method Used: X Hydrostatic Vacuum Other Test Equipment Used:. Date of Testing: 6/20/2018 Facility Naives: Vanco Truck — Auto Plaza Facility Address: 1033 W Charter Way Stockton Ca 95206 Facility Contact: Mike Boparai Phone: 209466-0833 2 91 3 4 2. TF,STTNG CONTRACTOR INFORMATION Company Name: ELITE IV CONTRACTORS Technician Conducting Test: 2CC /,t l/1c1G�1 Credentialsl: CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other (Specify) License Number(s): j(ie t t t?? J,? i�etic), 3. �PTf ,T, RTICKF.T TF,STIN<Y INFORMATION Comments — on repairs made prior to and recommended CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the inforutation contained in this report is true, accurate, and in full eontpliur:ce with legal requirements. Technician's Signature: 41/IC,�� Date: ` hZ6111V t State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements maybe more stringent. Test Method Used: X Hydrostatic Vacuum Other Test Equipment Used:. Equipment Resolution: Identify Spill Bucket (By Tank Number, Stored Product, etc.) 1 100 Octane 2 91 3 4 Bucket Installation Type: Direct Bury X Contained in Sump Direct Bury X Contained in Sump Direct Bury Contained in Sump Direct Bury Contained in Sump Bucket Diameter: 12" 12" Bucket Depth: 141/2 14" Wait time between applying vacuum/water and start of test: l Omin l Omin Test Start Time (Ti): 9am 9am Initial Reading (Ri): 13 %i" 127/8 Test End Time (TF): loam IOam Final Reading (RF): 13 %" 127/8 Test Duration (TF — Tj): 1 hr 1 hr Change in Reading (RF - Rj): No No Pass/Fail Threshold or Criteria: Pass Pass Test Result: X Pass ❑ Fail X Pass ❑ Fail Pass ❑ Fail ❑ Pass ❑ Fail Comments — on repairs made prior to and recommended CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the inforutation contained in this report is true, accurate, and in full eontpliur:ce with legal requirements. Technician's Signature: 41/IC,�� Date: ` hZ6111V t State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements maybe more stringent.