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Ll r� SWRCB, January 2006 This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (f applicable) should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: BW #98 - H & M MARKET I Date of Testing: JUL 20, 2009 Facility Address: 2501 E. JACKSON AVENUE, ESCALON, CA 95320 Facility Contact: ROHDA HENRY I Phone: (209) 549-5612 Date Local Agency Was Notified of Testing: JUL 13, 2009 Name of Local Agency Inspector (ifpresent during testing): MUNIAPPA NAIDU Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Technician Conducting Test: MIKE LAWRENCE Credentials': ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑ Other (Specie) License Number(s): 803705 (CSLB Contractor) -- 1048103 -UT (ICC Service Tech.) -- 90-1200 (SWRCB Tank Tester) 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other (Spec) Test Equipment Used: VISUAL Equipment Resolution: Identify Spill Bucket (By Tank Number, Stored Product, etc.) 87 FILL 91 FILL DIESEL FILL Bucket Installation Type: ® Direct Bury ❑ Contained in Sump ® Direct Bury ❑ Contained in Sump ® Direct Bury ❑ Contained in Sump ❑ Direct Bury ❑ Contained in Sump Bucket Diameter: 11.50" 11.50" 11.50" Bucket Depth: 15.50" 15.00" 20.00" Wait time between applying vacuum/water and start of test: 0 0 0 Test Start Time (Tj): 9:00 AM 9:00 AM 9:00 AM Initial Reading (Rj): 14.00" 13.50" 18.50" Test End Time (TF): 10:00 AM 10:00 AM 10:00 AM Final Reading (RF): 14.00" 13.50" 18.50" Test Duration (TF — Tj): 1 HR 1 HR 1 HR Change in Reading (RF - Rj): 0 0 0 Pass/Fail Threshold or Criteria: Test Result: ® Pass ❑ Fail Z Pass ❑ Fail 0 Pass ❑ Fail ❑ Pass ❑ Fail Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: =" ``'`` Date: JUL 20, 2009 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.