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MAfa-23-2011 11:35 Service Station Systems 408 938 8888 P.02 <br /> is 10 <br /> SWRCB,January 2006 <br /> Spill Bucket Testingr <br /> This form is intended for use by contractors performing annual testing of us spill containment structures. rhe completed form and <br /> printouts from tests(if applicable),should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: USA/TeSoro Date of Testing:2/23/11 <br /> Facility Address: 401 W. Kettleman Ln. Lodi, CA 95240 <br /> Facility Contact: Elizabeth Oku a 209 368-8787 <br /> Date Local Agency Was Notified of Testing: 2/16/11 <br /> Name of Local Agency Inspector (if present during testing). <br /> 2,TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test:,Jesse Rodriguez <br /> Credentialsi: [&CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ other(Specify) <br /> License Number(s): License:485184 IcC:8024952-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑vacuum ® Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 in. <br /> Identify Spill Bucket (Sy Tank 1 Fill Bucket2 Fill Bucket 3 4 <br /> Number,stored Product,etc.) 01 R8 u71 <br /> 02 Prem <br /> QX Direct Bury Q Direct Bury [3 Direct Bury ❑ Direct Bury <br /> Bucket Installation type: 0 Contained in Sump Q Contained in Sump Q Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 10.25 in. 10.25 in. <br /> Bucket Depth: 13.25 in. 13.25 in. <br /> Wait time between applying 15 min 15 min. <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 8:15am 8:15an1 <br /> initial Reading(F� ): 12.250 in. 12.250 in. <br /> Test End Time(Tp): 9,15am 9:15am <br /> Final Reading(N): 12.250 in. 12.250 in. <br /> Test Duration(TF-T,): 1.00 hr. 1.00 hr. <br /> Change in Reading(RF-R,): 0.0000 in. 0.0000 in. <br /> Pass/Fall Threshold or Criteria: ZERO LOSS ZERO LOSS <br /> .11Tl3St.R@5!t(t: p Pass ❑ Failr]x Pass ❑Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <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 /> hereby cert*that all the Information contained In this report is true,accurate,and In full compliance with legal requirements. <br /> Technician's Signature: �_ Date:2/23/11 <br /> t 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 />