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L] <br />0 SWRCB, January 2006 <br />1 i1111111111111 <br />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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />Facility Name: Gas Depot 2 1 Date of Testing: 06-23-10 <br />Facility Address: 1330 E. Yosemite Ave Manteca, CA 95336 <br />Facility Contact: Kevin Hur Phone: (209) 825-7722 <br />Date Local Agency Was Notified of Testing: 06/17/10 <br />Name of Local Agency Inspector (ifpresent during testing): <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 (Spec) <br />License Number(s): 883706 5250451 -UT <br />Test Method Used: X Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Standard <br />tape Measure <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />Tl: 87 <br />FILL <br />T2: 91 <br />FILL <br />T3: Diesel <br />FILL <br />Bucket Installation Type: <br />❑ Direct Bury <br />X Contained in Sump <br />❑ Direct Bury <br />X Contained in Sump <br />❑ Direct Bury ❑ Direct Bury <br />X Contained in Sump ❑ Contained in Sum <br />Bucket Diameter: <br />12" <br />12" <br />12" <br />Bucket Depth: <br />133/" <br />13" <br />17" <br />Wait time between applying <br />vacuum/water and start of test: <br />'min <br />'min <br />'min <br />Test Start Time (Ti): <br />1:02p.m. <br />1:01p.m. <br />1:03p.m. <br />Initial Reading (RI): <br />12'/" <br />11 Y2" <br />13" <br />Test End Time (TF): <br />2:02p.m. <br />2:01p.m. <br />2:03p.m. <br />Final Reading (RF): <br />12'/4" <br />11%2" <br />1399 <br />Test Duration (TF— Ti): <br />Ihr <br />Ihr <br />Ihr <br />Change in Reading (RF- RI): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16" <br />1/16" <br />1!1699 <br />TestResult: <br />X Pass ❑ Fail <br />X Pass ❑ Fail <br />X Pass ❑ Fail ❑ 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 Signature: <br />Date: 06-23-10 <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 />