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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 />Facility Name: Yosemite 76 Date of Testing: 3/30/2007 <br />Facility Address: 1700 Yosemite Avenue <br />Facility Contact: Amba Rai Phone: 209-823-7676 <br />Date Local Agency Was Notified of Testing: 3/16/2007 <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Confidence UST Services, Inc. <br />Technician Conducting Test: Kristopher Karns <br />Credentials': X CSLB Contractor X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): CSLB #804904 ICC # 5264406 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />X Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: Lake Test <br />Equipment Resolution: 0.0625" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 Regular <br />2 Super <br />3 4 <br />Bucket Installation Type: <br />X Direct Bury <br />❑ Contained in Sump <br />X Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury ❑ Direct Bury <br />❑ Contained in Sump ❑ Contained in Sum <br />Bucket Diameter: <br />12.00" <br />12.00" <br />Bucket Depth: <br />14.50" <br />14.00" <br />Wait time between applying <br />vacuum/water and start of test: <br />30 Min. <br />30 Min. <br />Test Start Time (TI): <br />2:15pm <br />2:15pm <br />Initial Reading (R,): <br />13.50" <br />13.00" <br />Test End Time (TF): <br />3:15pm <br />3:15pm <br />Final Reading (RF): <br />13.50" <br />13.00" <br />Test Duration (TF — TI): <br />1 hour <br />1 hour <br />Change in Reading (RF - RI): <br />0.00" <br />0.00" <br />Pass/Fail Threshold or <br />Criteria: <br />0.0625" <br />0.0625" <br />Test Result: <br />X Pass ❑ Fail <br />X Pass ❑ Fail <br />❑ Pass ❑ Fail ❑ 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 certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />1. <br />Technician's Signature: Date: 3/30/2007 <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 />