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ec(2� <br /> _us,t.iit.K CCIbFt1A'#Cr <br /> Spillet Testing Report Form <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: Shell Date of Testing: 02/12/2014 <br /> Facility Address: 16500 S. Harlan Road, Lathrop, CA 95330 <br /> Facility Contact: Nick Arbabian I Phone: (209)983-0381 <br /> Date Local Agency Was Notified of Testing: 02/07/2014 <br /> Name of Local Agency Inspector(tfpresent during testing): Thuy Tran <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ECO-CHEK Compliance, Inc. <br /> Technician Conducting Test: Nikola Zagorov <br /> Credentials': ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑ Other(Spec) <br /> License Number(s): 958763 A <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used:Tape Measure Equipment Resolution: 1/16 Inches <br /> Identify ill Bucket B Tank 1 Re ular 2 Pr „ , <br /> fY p ( y g emium 3 4 <br /> Number,Stored Product, etc..) <br /> Bucket Installation Type: ® Direct Bury ® Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 12 Inches 12 Inches <br /> Bucket Depth: 12 Inches 12 Inches <br /> Wait time between applying 10 Minutes 10 Minutes <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 01:10 PM 01:10 P <br /> Initial Reading(Rj): 9 3/4 Inches 8 3/4 Inches <br /> Test End Time(TF): 02:10 PM 02:10 PM <br /> Final Reading(RF): 9 3/4 Inches 8 3/4 Inches <br /> Test Duration(TF—Tj): 60 Minutes 60 Minutes <br /> Change in Reading(RF-Rj): 0 Inches 0 Inches <br /> Pass/Fail Threshold or i <br /> 1/16 Inches 1116 Inches <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail I E Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fair <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 /> Technician's Signature: rov Date:02/12/2014 <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 />