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Ll <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 (f applicable) should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: SOUTH BAY TIRE I <br />Date of Testing: 3/23/2011 <br />Facility Address: 1501 W. CHARTER WAY, STOCKTON, CA 95206 <br />Facility Contact: MIKE EL/ASON <br />I Phone: (209) 948-9412 <br />Date Local Agency Was Notified of T, -sting: 2/15/2011 <br />Name of Local Agency Inspector (f present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANK-�TEK ENVIRONMENTAL CORPORATION <br />Technician Conducting Test: MIKE LAWRENCE <br />Credentials': ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑ Other (Sped) <br />License Number(s): 803705 (CSLB Contractor) — 1048103 -UT (ICC Service Tech.) — 90-1200 (SIL+RCB Tank Tester) <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other (Soecify) <br />Test Equipment Used: TAPE MEASURE <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />87 FILL <br />DIESEL FILL <br />,,. E A� <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury ❑ Direct Bury <br />❑ Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: <br />11.50" <br />11.50" <br />Bucket Depth: <br />14" <br />141 - <br />Wait time between applying <br />vacuum/water and start of test: <br />0 <br />0 <br />Test Start Time (Ti): <br />1:10 PM <br />1:10 PM <br />Initial Reading (Ri): <br />12.50" <br />12.50" <br />Test End Time (TF): <br />2:10 PM <br />2:10 PM <br />Final Reading (RF): <br />12.50" <br />12.50" <br />Test Duration (TF — TI): <br />1 HR <br />1 HR <br />Change in Reading (RF - RI): <br />0" <br />0" <br />Pass/Fail Threshold or Criteria: <br />1/16" <br />1/16" <br />est Result:. <br />: Dass ❑ Fail, <br />, ®I'a�s ❑Fall <br />❑Pass ❑ :� aal <br />C �a �sE E 3 <br />r � z� �-. <br />Comments — (include information cn repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUC'T'ING 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 />Technician's Signature:'; Date: 3/23/2011 <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 />