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E <br />1 111111111111111111111111111 11111iiiiiiiiilill a , <br />0 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 />1. FACILITY INFORMATION --� —Date of Testing: 02-18-10 <br />Facility Name: WILSON WAY CHEVRON <br />Facility Address: 437 N. Wilson Way, Stockton CA 95205 <br />Facility Contact: Aman Mehroke I Phone: 209-942-2344 <br />Date Local Agency Was Notified of Testing: 02-09-10 <br />Name of Local Agency Inspector (ii(present during testing): Stacy Rivera <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: RELIABLE PETROLEUM SERVICES INC. <br />Technician Conducting Test: Robert Barnhart <br />Credentials': X CSLB Contractor X ICC Service Tech. 0 SWRCB Tank Tester 0 Other (Specify) <br />License Number(s): 883706 5252540 -UT <br />Test Method Used: X Hydrostatic 0 Vacuum 0 Other <br />Test Equipment Used: Standard Tape Measure Equipment Resolution: -- <br />Identify Spill Bucket (By Tank —TI: Regular T2: Supreme 3 4 <br />Number, Stared Product, etc. <br />Bucket Installation Type: <br />0 Direct Bury <br />X Contained in Sump <br />0 Direct Bury 0 Direct Bury <br />X Contained in Sump 0 Contained in Sump <br />0 Direct Bury <br />D Contained in Sump <br />Bucket Diameter: <br />12" <br />12" <br />Bucket Depth: <br />15 V2" <br />13%11 <br />Wait time between applying <br />vacuum/water and start of test: <br />I min. <br />I min. <br />Test Start Time (Ti): <br />11:08a.m <br />11:08a.m <br />Initial Reading (Ri): <br />14%19 <br />14 %" <br />Test End Time (TF): <br />12:08p.m <br />12:08p. m <br />Final Reading (RF): <br />14%11 <br />131/" <br />Test Duration (TF– Tr): <br />I hour <br />1 hour <br />Change in Reading (RF- RI): <br />0 <br />0 <br />ED <br />Pass/Fail Threshold or <br />Criteria: <br />1/161 <br />1/1611 <br />2103Pass <br />Test Result: <br />r"1rn1Mdh"+. <br />X Pass 0 Fail <br />X Pass 0 Fail D Fail <br />Pass 0 Fail <br />_ <br />- --------- I., , ur, repuirs maae prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby cert j& that all the information contained In this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: I" <br />Date:02-18-10 <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 />