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r <br />V <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 />11- FACILITY INF(IRMATICIN <br />Facility Name: Unocal Date of Testing: 12/18/13 <br />Facility Address: 2701 March Ln. Stockton, CA 95219 <br />Facility Contact: Darren Eppler (209) 473-7337 <br />Date Local Agency Was Notified of Testing: 12/5/13 <br />Name of Local Agency Inspector (if present during testing): Garrett Backus <br />7 TF.qTINt' . CnNTRArTnR INFnRMATInN <br />Company Name: SerVice Station Systems <br />Technician Conducting Test: Kris Bell <br />Credentlalsi: (8] CSLB Contractor [@ ICC Service Tech. 0 SWRCB Tank Tester []Other (Specify) <br />License Number(s): License: 485184 ICC:5297793-UT <br />kw -1 <br />Test Method Used: <br />Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: Measuring Tape <br />Equipment Resolution: 1 /16 in. <br />Idenfify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />I Fill Bucket <br />01 Re u <br />2 Fill Bucket <br />02 Prem <br />3 Fill Bucket 4 <br />03 Diesel <br />Bucket Installation Type: <br />Direct Bury <br />❑ Contained In Sump <br />Direct Bury <br />0 Contained In Sump <br />Direct Bury C] Direct Bury <br />0 Contained in Sump 0 Contained in Sump <br />Bucket Diameter: <br />13.00 in. <br />13.00 in. <br />13.00 In. <br />Bucket Depth: <br />12.50 in. <br />12.50 in. <br />13.50 in. <br />Wait time between applying <br />vacuum/Water and start of test: <br />5 min. <br />5 min. <br />5 min. <br />Test Start Time (TI <br />9:40arn <br />9:40arn <br />9:40arn <br />Initial Reading (F, <br />12.000 in. <br />12.000 in. <br />13.500 in. <br />Test End Time (TF <br />10:40arn <br />10:40am <br />10:40arn <br />Final Reading (F:F): <br />12.000 in. <br />12.000 in. <br />13.500 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 />0.0000 in. <br />0.0000 in. <br />0.0000 in. <br />Pass/Fall Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />At mass b❑ <br />i'm Pus:. ❑Fit <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, accurateand in full compliance with legal requirements. <br />Technician's Signature, Date: 12/18/13 <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 />