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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 ownerloperstor for submittal to the local regulatory agency. <br />1 _ FACILITY INFORMATION <br />Facility Name: USA/Tesoro <br />Date of Testing: 2/21113 <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: 2/12/13 <br />Name of Local Agency Inspector (if present during testing): Aris Cacapit <br />Company Name: Service Station Systems <br />Technician Conducting Test: Myke Briggs <br />Credentials : ®CSLB Contractor Q ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): License: 485184 ICC:8033115-UT <br />��JI��i•i�f��e��>tI►�iniciZ!1-i���>•t.��•�r <br />Test Method Used: <br />❑x Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: Measuring Tape <br />13.125 in. <br />Equipment Resolution: 1/16 in. <br />11:00am <br />11:00am <br />Final Reading (RF ): <br />13.500 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product etc.) <br />1 Fill Bucket <br />01 Re u <br />2 Fill Bucket <br />02 Prem <br />3 4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />[XJ Direct Bury <br />❑ Contained in Sump <br />F-1Direct Bury ❑ Direct Bury <br />❑ Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: <br />13.00 in. <br />13.00 in. <br />Bucket Depth: <br />14.00 in. <br />14.50 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />1 min. <br />1 min. <br />Test Start Time (T, ): <br />10:00am <br />10:00am <br />Initial Reading (R, ): <br />13.500 in. <br />13.125 in. <br />Test End Time (TF ): <br />11:00am <br />11:00am <br />Final Reading (RF ): <br />13.500 in. <br />13.125 in. <br />Test Duration (TF -T,): <br />1.00 hr. <br />1.00 hr. <br />Change in Reading (RF - R, ): <br />0.0000 in. <br />0.0000 in. <br />Pass/Fail Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />1111ITI! 11111!1! 1 I'll 3301002= <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: 2/21/13 <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 />