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C0 <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: ARCO # 02093 CC18022760 <br />Date of Testing: 12/18/2007 <br />Facility Address: 3425 TRACY BLVD , TRACY, CA, 95376 <br />Facility Contact: MANAGER <br />I Phone: (2 0 9) 835-1605 <br />Date Local Agency Was Notified of Testing: 12/02/2007 <br />Name of Local Agency Inspector (if present during testing): RAY VON FLUE <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: DENNIS RUE <br />Credentials :E1 <br />X❑ Hydrostatic <br />CSLB Contractor <br />E <br />ICC Service Tech. <br />11 <br />SWRCB Tank Tester <br />E <br />Other (Specify) I CC <br />License Number: 5246067 -UT <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 />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />X❑ Hydrostatic <br />El Vacuum <br />1:1 Other <br />Test Equipment Used: TAPE MEASURE <br />Equipment Resolution: VISUAL <br />Identify Spill Bucket(By Tank <br />t 1 PRE FILL <br />2 2 REG FILL <br />3 3 REG FILL 4 4 REG FILL <br />Number, Stored Product, etc.) <br />Direct Bury <br />[--jDirect Bury <br />F -]Direct Bury Direct Bury <br />Bucket Installation Type: <br />Q Contained in Sump <br />Q Contained in Sump <br />Q Contained in Sump Q Contained in Sump <br />Bucket Diameter: <br />13 <br />13 <br />13 13 <br />Bucket Depth: <br />15 <br />15 <br />15 15 <br />Wait time between applying <br />5 <br />5 <br />5 5 <br />vacuum/water and starting test: <br />Test Start Time (TI ): <br />1030 <br />1030 <br />0930 0930 <br />Initial Reading (RI ): <br />14 <br />14 <br />14 14 <br />Test End Time (TF ): <br />1130 <br />1130 <br />1030 1030 <br />Final Reading (RF ): <br />14 <br />14 <br />14 14 <br />Test Duration: <br />60 MINS. <br />60 MINS. <br />60 MINS. 60 MINS. <br />Change in Reading (R F - RI ): <br />0 <br />0 <br />0 0 <br />Pass/Fail Threshold or <br />P <br />P <br />P P <br />Criteria: <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, <br />and in full compliance with legal requirements. <br />Technician's Signature: e -z '� A <br />Date: 12/18/2007 <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 />