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E <br />Z <br />41111 ;1111114 11111��Iijrgjiiiiijjiiij 11,11���!��illilli��illi <br />E <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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />Facility Name: Shell/Tesoro, <br />I Date of Testing: 1/28/13 <br />Facility Address: 35 N. Cherokee Ln. Lodi, CA 95240 <br />Facility Contact: Grace Keller (209) 369-1525 <br />Date Local Agency Was Notified of Testing: / / <br />Name of Local Agency Inspector (if present during testing): Aris Cacapit <br />Company Name: Service Station Systems <br />Technician Conducting Test: Myke Briggs <br />Credentialsi: [Z] CSLB Contractor Z ICC Service Tech. F] SWRCB Tank Tester E] Other (Specify) <br />License Number(s): License:485184 ICC:8033115-UT <br />Test Method Used: <br />Q Hydrostatic <br />El vacuum <br />E] Other <br />Test Equipment Used: Measuring Tape <br />Equipment Resolution:11/1 6 in. <br />...... . ... <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 Fill Bucket <br />01 Re <br />2 Fill Bucket <br />02 Prem <br />3 Fill Bucket 4 <br />03 Diesel <br />Bucket Installation Type: <br />QDirect Bury <br />❑ Contained in Sump <br />Direct Bury <br />f-1 Contained in Sump <br />MX Direct Bury r71 Direct Bury <br />[3 Contained in Sump 0 Contained in Sump <br />Bucket Diameter: <br />12.00 in. <br />12.00 in. <br />12.00 in. <br />Bucket Depth: <br />14.00 in. <br />14.00 in. <br />13.75 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />I min. <br />I min. <br />I min, <br />Test Start Time (TI <br />1 0:00am <br />10:00am <br />1 0:00am <br />Initial Reading (RI <br />13.875 in. <br />13,500 in. <br />13.000 in. <br />Test End Time (TF <br />I 1:00am <br />I 1:00am <br />1 1:00am <br />Final Reading (F?F): <br />13.875 in. <br />13.500 in. <br />13.000 in. <br />Test Duration (TF - T 1): <br />1.00 hr. <br />1.00 hr. <br />1.00 hr. <br />Change in Reading (RF - R, <br />0.0000 in. <br />0.0000 in. <br />0.0000 in. <br />Pass/Fail Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />Tdit Result:Pass <br />P$, 0- <br />�]&'' E] Fail <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />hereby certify that all the information contained in this report is true, accurateand in full compliance with legal requirements. <br />Technician's Signature: Date:. 1/28/13 <br />1 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 />