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0 <br />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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />Facility Name: Wilson Way Chevron Date of Testing: 02/16/2012 <br />Facility Address: 437 N. Wilson Way <br />Facility Contact: Aman Mehroke Phone: 209-942-2344 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (rfpresent during testing): Jeff Wong <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 />Test Method Used: xHydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Standard Tape Measure <br />Equipment Resolution: N/A <br />3 T3: <br />4 T4: <br />Identify Spill Bucket (By Tank 1 T1: 87 Fill <br />Number, Stored Product, etc. <br />2 T2: 91 Fill <br />Bucket Installation Type: Direct Bury <br />x Contained in Sump <br />Direct Bury <br />x Contained in Sump <br />Direct Bury <br />❑ Contained in Su!np <br />Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter. 12" <br />12" <br />Bucket Depth: 17''/2" <br />16" <br />Wait time between applying 1 minute <br />vacuum/water and start of test: <br />1 minute <br />Test Start Time (Tj): 1:54 p.m. <br />1:55 p.m. <br />Initial Reading (Rj): 14 7/8" <br />131/2" <br />Test End Time (TF): 2:54 p.m. <br />2:55 p.m. <br />Final Reading (RF): 14 7/8" <br />13''/2" <br />Test Duration (TF— TI): 1 hr <br />1 hr <br />Change in Reading (RF- Rj): 0 <br />0 <br />Pass/Fail Threshold or 1/16" <br />Criteria: <br />1/16" <br />Test esult: 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 certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signa e• Date 02/16/2012 <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 />