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4 * . 0 0 a 0 111111 <br />RECEIVEL <br />SWRCB, January 2006 <br />FEB 2 6 2015 <br />This form is intended for use by contractors performing annual testing of UST spill containment structures, The 0 <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local re <br />RN MENTAL, <br />XCA—U ria040'riisciirr <br />1. FACILITY INFORMATION <br />Facility Name: Shell[TeSoro T <br />-Pate of Testing: 01/28/15 <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: 1/13/15 <br />Name of Local Agency Inspector (if present during testing): ArisVeloso <br />Company Name: service Station Systems <br />Technician Conducting Test: Randy Wilkerson <br />Credentialsi: [@ CSLB Contractor [K ICC Service Tech. [3 SWRCB Tank Tester E3 Other (Specify) <br />License Number(s): License: 485184 ICC:5258560-UT <br />Test Method Used: (Z) Hydrostatic vacuum [3 Other <br />Test Equipment Used: Measuring Tape Equipment Resolution:1/1 6 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 Fill Bucket <br />01 - Re <br />2 FiII Bucket <br />3 Fill Bucket 4 <br />03 - Diesel <br />Bucket Installation Type: <br />C] Direct Bury <br />Contained in Sump <br />F1 Direct Bury <br />Contained in Sump <br />C] Direct Bury C3 Direct Bury <br />Contained in Sump E] Contained in Sump <br />Bucket Diameter: <br />12.00 in. <br />12.00 in. <br />12.00 in, <br />Bucket Depth: <br />13.00 in. <br />13.25 in. <br />13.00 in. <br />Wait time between applying <br />vacuum /water and start of test: <br />10 min. <br />10 min, <br />10 min. <br />Test Start Time (Ti <br />9:30am <br />9:30am <br />9:30am <br />Initial Reading (F� <br />12.00 in. <br />12.50 in. <br />12.13 in. <br />Test End Time (TF. <br />10:30am <br />10:30am <br />10:30am <br />Final Reading (F� <br />12.00 in. <br />12.50 in. <br />12.13 in. <br />Test Duration (TF -T,): <br />1,00 hr. <br />1.00 hr. <br />1.00 hr. <br />Change in Reading (RF - R, <br />0.000 in. <br />0.000 in. <br />0.000 in, <br />Pass/Fall Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />Test Result- <br />Pass C],Fail <br />Pass , , [] Fail <br />Pass0 Fail, E] Pass E] Failj <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the infor#iatlon contained in this report is true, accurateand in full compliance with legal requirements. <br />Technician's <br />Date: 01/28/15 <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 />