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0 <br />SWRCB, January 2006 <br />IIIIIIIIIII <br />i 1 1 1 <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 (af applicable) should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: CRLLC #5446 <br />Date of Testing: 5/18/2012 <br />Facility Address: 1403 COUNTRY CLUB BLVD, STOCKTON, CA 95204 <br />Facility Contact: ALLEN FAAS' Phone: (925) 884-0800 <br />Date Local Agency Was Notified of Testing: 5/7/12 <br />Name of Local Agency Inspector (afpresent during testing): NONE PRESENT <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br />Technician Conducting Test: RICHARD THOMAS <br />Credentials': ® CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): 803705 (CSLB Contractor) — 5254736 -UT (ICC Service Tech.) — 06-1672 (SWRCB Tank Tester) <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other (Spec) <br />Test Equipment Used: VISUAL - TAPE MEASURE <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />DIESEL FILL <br />87 FILL <br />91 FILL <br />WASTE OIL FILL <br />Bucket Installation Type: <br />❑ Direct Bury <br />® Contained in Sump <br />❑ Direct Bury <br />® Contained in Sump <br />❑ Direct Bury <br />® Contained in Sump <br />❑ Direct Bury <br />® Contained in Sump <br />Bucket Diameter: <br />14" <br />14" <br />14" <br />14" <br />Bucket Depth: <br />12" <br />12.25" <br />12" <br />10" <br />Wait time between applying <br />vacuum/water and start of test: <br />10 MIN <br />10 MIN <br />10 MIN <br />10 MIN <br />Test Start Time (TI): <br />9:00 AM <br />9:00 AM <br />9:00 AM <br />9:00 AM <br />Initial Reading (Rj): <br />12" <br />12.25" <br />12" <br />8.75" <br />Test End Time (TF): <br />10:00 AM <br />10:00 AM <br />10:00 AM <br />10:00 AM <br />Final Reading (RF): <br />12" <br />12.25" <br />12" <br />8.75" <br />Test Duration (TF — TI): <br />1 HR <br />1 HR <br />1 HR <br />1 HR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or Criteria: <br />Tesf.Result. <br />Pass ❑',Fall <br />® Pass ❑Fail <br />®Pass <br />❑ Fail <br />®' Pass ❑ >f"`aiI <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: �---a- " t ----s Date: 5/18/2012 <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 />