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FEB -14-2012 08:00 Service Station Systems 408 938 8888 P.02 <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 ownerloperator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: 5hell/Tesoro Date of Testing: l/18/12 <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: 1/10/12 <br />Name of local Agency Inspector (if present during testing). <br />2, TESTING CONTRACTOR INFORMATION <br />Company Name:Setvice Station Systems <br />Te .`:nician Conducting +'est- Ryan Casey <br />Credentials : ® CSLB Contractor Q ICC Service Tech. ❑ SWRCB Tank Tester Q Other (Specify) <br />License Number(s): License: 485184 ICC -8057554 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: jA] Hydrostatic ® Vacuum ❑ Other <br />Test Equipment used: Measuring Tape Equipment Resolution. 1/ 16 in. <br />Identity $pill Bucket (ay Tank 1 Fill Bucket <br />: amber, Stored Product, etc.) 01 Re u <br />® Direct Bury <br />Bucket Installation Type: <br />j] Contained in Sump <br />2 Fill Bucket 3 Fill Bucket <br />02 Prem 03 Diesel <br />4 <br />® Direct Bury [X Direct Bury <br />❑Contained in Sump � Contained in Sump <br />Q Direct Bury <br />Contained in Sump <br />Bucket Diameter: <br />12.00 in. <br />12.00 in. 12.00 in. <br />Bucket Depth: <br />12.75 in. <br />12,75 in. 12.75 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />15 min. <br />15 min. 15 min. <br />Test Stan Time (T, ): <br />9:15arn <br />9:15am 9:15am <br />Initial Reading (R, ): <br />11.500 in. <br />11.500 in, 11.500 in. <br />Test End Time (TF }: <br />10:15am <br />10:15am 10:15am <br />Final Reading (F� ): <br />11.500 in. <br />11.500 in. 11.500 in. <br />Test Duration jr. - T 1): <br />1.00 hr. <br />1.00 hr, 1.00 hr. <br />Change in Reading (RF - R, ): <br />0.0000 in. <br />0.0000 in. 0.0000 in. <br />Pass/Fail Threshold or Criteria: <br />ZE=RO LOSS <br />ZERO LOSS ZERO LGSS <br />Test Result: Pass © Fail <br />Pass [J Fail b 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 /n full compliance with legal requirements. <br />Technician's Signature: rte' Date: 1/18/12 <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 />