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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 (if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br />pFacility Name: USA/Tesoro Date of Testing: 2/18114 <br />. ' F I ity !Ad <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: 1/24/14 <br />Name of Local Agency Inspector (if present during testing): ArisCacapit <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Service Station Systems <br />Technician Conducting Test: Kris Bell <br />Credentialsi: [S] CSLB Contractor (@ ICC Service Tech. Ej SWRCB Tank Tester C] Other (Specify) <br />License Number(s): License: 485184 lcc:5297793-UT <br />ff,9U#17XF_.W MW <br />Test Method Used: <br />IS] Hydrostatic <br />C] vacuum <br />Q Other <br />Test Equipment Used, Measuring Tape <br />Equipment Resolution:)/16 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />I Fill Bucket <br />01 Re <br />2 Fill Bucket <br />02 Prem <br />3 4 <br />- cket Installation Type: <br />Direct Bury <br />C] Contained in Sump <br />Direct Bury <br />E] Contained in Sump <br />Direct Bury E] Direct Bury <br />Contained in Sump ❑Contained in Sump <br />[Bu <br />Bucket Diameter: <br />13.00 in. <br />13.00 in. <br />ucket Depft <br />Bucket <br />14,00 in. <br />13.00 in. <br />Wait ime betweenappyng <br />vacuumtwater and start of test <br />5 min. <br />5 min. <br />Test Start Time (Ti <br />8:58am <br />Initial Reading (R <br />13.000 in. <br />12.500 in. <br />Test End Time (TF <br />9:58am <br />9:58am <br />Final Reading (F� <br />13.000 in, <br />12,500 in. <br />Test Duration (TF - T 1); <br />1.00 hr. <br />1.00 hr. <br />Change in Reading (RF -111 <br />0.0000 in. <br />0.0000 in. <br />Pass/Fail Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />Test Result:., <br />pass ­,OFqil <br />Fall <br />Pass Ej Fait-, <br />Comments: Include information on repairs made prior to testing, and recommended follow-up for failed tests. <br />- - _-_--_-------- <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report Is trueaccurateand In full compliance with legal requirements, <br />Technician's Signature, Date: /18/14 <br />1 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 />