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11 <br />1�1 <br />SWRC8, January 2006 <br />This form is intended for use by contractors performing annual testi UST spill containment structures. The completed form and <br />printouts from tests (if applicable), should be provided to the facifiVoof owner/operator erator for submittal to the local regulatory agency. <br />Facility Name: Shell/Tesoro <br />Date of Testing: 01 /24/18 <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: 1/10/18 <br />Name of Local Agency Inspector (if present during testing): Cesar Ruvalcaba <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name:Service Station Systems... <br />Technician Conducting Test: Myke Briggs <br />Credentials : [@ CSLB Contractor M ICC Service Tech. [3 SWRCB Tank Tester E] Other (Specify) <br />License Number(s): License: 485184 ICC:8033115-UT <br />Test Method Used: <br />[X] Hydrostatic <br />0 Vacuum <br />0 Other <br />Test Equipment Used: Measuring Tape <br />Equipment Resolution:)/16 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) 11 <br />I Fill Bucket <br />01 - Re <br />2 Fill Bucket <br />1 02 - Prem <br />Fill Bucket 4 <br />03 - Diesel <br />Bucket Installation Type: <br />[2) Direct Bury <br />❑ Contained in Sump <br />Direct Bury <br />❑ Contained in Sump <br />M Direct Bury E] Direct Bury <br />❑ Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: <br />13.00 in. <br />13.00 in. <br />13.00 in. <br />Bucket Depth: <br />13.00 in. <br />13.00 in. <br />13.00 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />I min. <br />1 min. <br />1 min. <br />Test Start Time (TI <br />9:45am <br />9:45am <br />9:45am <br />Initial Reading (Fi <br />12.500 in. <br />12.000 in. <br />12.000 in. <br />Test End Time (TF <br />10:45am <br />10:45am <br />10:45am <br />Final Reading (RF <br />12.500 in. <br />12.000 in. <br />12.000 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 />PaWFail Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />Test Result: I <br />IM Pass C] Fail <br />Pass Fail <br />Pass [I Fail Pass 0 Fail <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the Information contained in this report Is true, accurateand in full compliance with legal requirements. <br />rw�—fflffio <br />Technician's <br />01/24/18 <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 />