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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 owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Statewide Petroleum Date of Testing: 07/20/10 <br />Facility Address: 1700 E. Yosemite Avenue, Manteca 95336 <br />Facility Contact: Randy Singh Phone: 209-628-3300 <br />Date Local Agency Was Notified of Testing: 07/09/10 <br />Name of Local Agency Inspector (afpresent during testing): Aris Cacapit <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Reliable Petroleum Services Inc. <br />Technician Conducting Test: Guadalupe Sanchez <br />Credentials': X CSLB Contractor X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): 883706 5250451 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: X Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Standard <br />Measure <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />-Ta -pe- <br />Tl: 87 Fill <br />T2: 91 Fill <br />3 <br />4 <br />Bucket Installation Type: <br />X Direct Bury <br />❑ Contained in Sump <br />X Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />12" <br />12" <br />Bucket Depth: <br />13 % " <br />14" <br />Wait time between applying <br />vacuum/water and start of test: <br />IIN. <br />1IN. <br />Test Start Time (TI): <br />9:14A. <br />9:15A. <br />Initial Reading (RI): <br />12 7/8" <br />13 1/8" <br />Test End Time (TF): <br />10:14A.M <br />10:15A.M <br />Final Reading (RF): <br />12 7/8" <br />131/8" <br />Test Duration (TF — T,): <br />1HR. <br />IHR. <br />Change in Reading (RF - RI): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16" <br />1/16" <br />Test Result: <br />X Pass ❑ Fail <br />X Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑Pass ❑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 certt& that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: Date:07/20/10 <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 />