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MAR-21-2012 12:22 Service Station Systems 408 938 8888 P.02 <br /> Spill Bucket Testing Report Form SWRCB,January 2008 <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(if applicable),should be provided to the facility owner/operalor for submittal to the local requlatary agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: USA/Tesoro Date of Testing:2/23/12 <br /> Facility Address; 401 W. Kettleman Ln, Lodi, CA 95240 <br /> Facility Contact: Elizabeth Okupe 209)368-8787 <br /> Date Local Agency Was Notified of Testing: 2/15/12 <br /> Name of Local Agency Inspector (ry present during testing): Ads and Ray <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test;Steve Parmenter <br /> Creden6alsi; ®CSLB Contractor ©ICC Service Tech, Q SWRCB Tank Tester Q Other(Spsoiry) <br /> License Number(s): License:485184 icc:5311561-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method used; ®Hydrostatic Q vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:l/16 in. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 4 <br /> Number,Stored Product,etc.) 01 Re u 02 Prem <br /> Bucket installation Type: ® Direct Bury ®Direct Bury Q Direct Bury ❑Direct Bury <br /> []Cantained in Sump ❑Contained in Sump []Contained in Sump ® Contained in Sump <br /> Bucket Diameter: 13,00 in. 13.00 in. <br /> Bucket Depth: 12.00 in. 12,00 in. <br /> Wait time between applying <br /> vacuum/water and start of test: 1 min. 1 min. <br /> Test start Time(TI): 9:24am 9:24am <br /> Initial Reading(Ri ): 12.000 in, 12.000 in. <br /> Test End Time(TF): 10:24am 10:24am <br /> Final Reading(N), 12.000 in. 12.000 in. <br /> Test Duration(TF•T 1): 1.00 hr. 1.00 hr. <br /> Change in Reading(RF-RI}: 0.0000 in. 0.0000 in, <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS <br /> Test Result xQ Pass ®Fail ®Pass Q Fail Pass Q Fail [j Pass []Pail <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/Marmatfon contained In this report is true,accurate and in fall compliance with legal requirements. <br /> r� <br /> Technician's Signature: - _—•....... Date 2/23/12 <br /> t State laws and regulations do not currently require testing to be performed by a qualified contmctor,However,local requirements <br /> may be more stiringent. <br />