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150806-423 <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 />1. FACILITY INFORMATION <br />Facility Name: Mid City Ca FO Regen Date of Testing: 09/03/15 <br />Facility Address: 13850 Devries Road <br />Facility Contact: Jonathan Pakele Phone: 916-439-6042 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency In ector (i resent du rin testin : Aris Veloso <br />Company Name: Sunwest engineering inc. <br />Technician Conducting Test: Ruben Becerra <br />Credentials : CSLB Contractor[] ICC Service Tech.21 SWRCB Tank Tester[] Other (Specify) <br />License Number(s): 5302139 <br />Test Method Used: Hydrostatic <br />Test Equipment Used: measuring tape/ visual <br />Identify Spill Bucket (by Tank <br />Number, Stored Product, etc. <br />UST#313/ Diesel <br />Bucket Installation Type: <br />irect Bury <br />Contained in Sum <br />irect Bury irect Buryirect <br />ontained in Sum ontained in Sum <br />Bury <br />ontained in Sum <br />Bucket Diameter: <br />12" <br />Bucket Depth: <br />12" <br />Wait time between applying <br />vacuum/water and start of test: <br />15 minutes <br />Test Start Time (Ti): <br />9:00am <br />Initial Reading (RI): <br />11" <br />Test End Time (TF): <br />10:00am <br />Final Reading (RF): <br />11" <br />Test Duration (TF- Tj): <br />60 minutes <br />Change in Reading (RF- Rj): <br />0.000" <br />Pass/Fail Threshold or <br />Criteria: <br />0.002" <br />ff{ <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 in full compliance with legal requirements. <br />Digitals sg* by Rohn Ban for 0190423 <br />Technician's Signature: NION0151028:52 Date: 9/3/2015 <br />I 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 />Wednesday, September 16, 2015 b6ttanyl <br />