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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 <br />Facility Name: PARKWOODS SHELL Date of Testing: 5/7/2015 <br />Facility Address: 1612 W. HAMMER LN. STOCKTON, CA 95209 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing :4/14/15 %Of " I VE <br />Name of Local Agency Inspector (f present during testing): FAHTINA ®®A %> — FV —, <br />2. TFSTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 d Street Galt, CA 95632 (209) 744- <br />Technician Conducting Test: ❑ Lyle D. Nimmo ® Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3_ CP11.I, RITCKFT TFSTING INFORMATION <br />Test Method Used: <br />® Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: TAPE MEASURE, H2O <br />Equipment Resolution: <br />1/16" <br />Identify <br />y Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 <br />3 91 4 DIESEL <br />Bucket Installation Type: <br />® Direct Bury <br />❑Contained in Sump <br />E] Direct Bury <br />❑Contained in Sump <br />®Direct Bury <br />F-1 Contained in <br />Sump <br />Z Direct Bury <br />F-1 Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />14 1/2 <br />14 1/2 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />Test Start Time (Tj): <br />1340 <br />1340 <br />1340 <br />Initial Reading (Rj): <br />13 1/2 <br />13 1/2 <br />13 <br />Test End Time (TF): <br />1440 <br />1440 <br />1440 <br />Final Reading (RF): <br />13 1/2 <br />13 1/2 <br />13 <br />Test Duration (TF — Ti): <br />HR <br />HR <br />HR <br />HR <br />Change in Reading (RF - RI): <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />® Pass El Fail <br />❑ Pass ❑ Fail <br />0 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 Signature Date: 5-7-15 <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 />