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L'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 />1. FACILITY INFORMATION <br />Facility Name: SHELL FOOD MART I Date of Testing: February 23, 2009 <br />Facility Address: 2320 N. El Dorado Street, Stockton, CA 95204 <br />Facility Contact: Bob Lutz I Phone: 209.483.7671 <br />Date Local Agency Was Notified of Testing: February 20, 2009 <br />Name of Local Agency Inspector (fpresent during testing): Garrett Backus <br />W I) "a Q1 0[11 ' <br />Company Name: STOCKTON SERVICE STATION EQUIPMENT CO. INC. <br />Technician Conducting Test: Eric Molgaard <br />Credentials': ❑ CSLB Contractor x ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): ICC TECH 5250200UT <br />3_ SPILL BUCKET TESTING INFORMATION <br />Test Method Used: X Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank 1 <br />Number, Stored Product, etc. Premium <br />2 <br />Regular <br />3 4 <br />Diesel <br />Bucket Installation Type: x Direct Bury <br />❑ Contained in Sump <br />x Direct Bury <br />❑ Contained in Sump <br />x Direct Bury ❑ Direct Bury <br />❑ Contained in Sump ❑ Contained in Sum <br />Bucket Diameter: 12 inch <br />12 inch <br />12 inch <br />Bucket Depth: 15 inch <br />15 inch <br />15 inch <br />Wait time between applying 1 minute <br />vacuum/water and start of test: <br />3 minutes <br />5 minutes <br />Test Start Time (Ti): 9:15 a.m. <br />9:15 a.m. <br />9:15 a.m. <br />Initial Reading (Ri): 1.3 from top <br />1.3 from top <br />1.3 from top <br />Test End Time (TF): 10:15 a.m. <br />10:15 a.m. <br />10:15 a.m. <br />Final Reading (RF): 1.3 from top <br />1.3 from top <br />1.3 from top <br />Test Duration (TF — Ti): 1 hour <br />1 hour <br />1 hour <br />Change in Reading (RF - Ri): -0- <br />-0- <br />-0- <br />Pass/Fail Threshold or > W6 inch <br />Criteria: <br />> 1,116 inch <br />> 1/16 inch <br />Test Result: I x Pass ❑ Fail <br />xPass ❑ 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: Eric Norgaard Date: February 23, 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 />