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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: California Stop Date of Testing: 03/27/2009 <br />Facility Address: 2224 S. Manthey Road Stockton CA 95206 <br />Facility Contact: Nancy Le Phone: (209) 462-7621 <br />Date Local Agency Was Notified of Testing : 03/24/2009 <br />Name of Local Agency Inspector (rf present during testing): Muni <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: EPIC Compliance Systems, Inc. <br />Technician Conducting Test: Keith Huston <br />Credentials': B CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 880430 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />® Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: 1 Hour LAKE Test <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 Regular <br />2 Premium <br />3 Diesel 4 <br />Bucket Installation Type: <br />El Direct Bury <br />❑ Contained in Sump <br />El Direct Bury <br />❑ Contained in Sump <br />El Direct Bury ❑ Direct Bury <br />❑ Contained in Sump ❑ Contained in Sum <br />Bucket Diameter: <br />12" <br />12" <br />12" <br />Bucket Depth: <br />14" <br />14" <br />14" <br />Wait time between applying <br />vacuum/water and start of test: <br />5 min. <br />5 min. <br />5 min. <br />Test Start Time (TI): <br />10:15 AM <br />10:15 AM <br />10:15 AM <br />Initial Reading (RI): <br />133/8- <br />11 3/4" <br />10 10/16" <br />Test End Time (TF): <br />11:15 AM <br />11:15 AM <br />11:15 AM <br />Final Reading (RF): <br />13 3/8" <br />11 3/4" <br />10 10/16" <br />Test Duration (TF — TI): <br />1 hr. <br />1 hr. <br />1 hr. <br />Change in Reading (RF - RI): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16" hr. <br />1/16" hr. <br />1/16" hr. <br />Test Result. <br />® Pass OFail <br />0.'11ass CI Fail <br />D Pass ❑ Fail O hss ❑ 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 />Technician's Signature: <br />Date: 03/27/2009 <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 />