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C 1,1 SWRCB, January 2006 This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: TRACY TRUCK STOP Date of Testing: March 8, 2007 Facility Address: 3940 N. Tracy Blvd., Tracy, CA 95304 Facility Contact: Debbie Phone: 209-865-5006 Date Local Agency Was Notified of Testing :March 07, 2007 Name of Local Agency Inspector (f present during testing): Willie Ng 2. TESTING CONTRACTOR INFORMATION Company Name: STOCKTON SERVICE STATION EQUIPMENT CO. INC. Technician Conducting Test: Mike Jones Credentials': ❑ CSLB Contractor X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) License-Number(s): 5254644-U1 CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: Nike _Tones Date: March 8, 2007 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. 3. SPILL BUCKET TESTING INFORMATION Test Method Used: Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: Equipment Resolution: Identify Spill Bucket (By Tank Number, Stored Product, etc. 1 Supreme Unlead T-2, Octane 92 2 Diesel T-3 West 3 Diesel T-4, East 4 Bucket Installation Type: Direct Bury ❑ Contained in Sum W Direct Bury ❑ Contained in Sump W Direct Bury ❑ Contained in Sump ❑ Direct Bury ❑ Contained in Sum Bucket Diameter: 11" 11" 11" Bucket Depth: 12" 12" 12" Wait time between applying vacuum/water and start of test: Test Start Time (TI): 10:19 A.M. 10:19 A.M. 10:19 A.M. Initial Reading (RI): 9-5/8" 10-3/4" 8-1/2" Test End Time (TF): 11:19 A.M. 11:19 A.M. 11:19 A.M. Final Reading (RF): [:Test Duration (TF — TI): 1 Hour 1 Hour 1 Hour Change in Reading (RF - RI): Pass/Fail Threshold or Criteria: est Rent; Pass .� llas aa# Ps FI ❑ Pa'slaazl Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) Removed and added sealant to fill Atp, T-4, West. Replaced fill cap on T-3, East. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: Nike _Tones Date: March 8, 2007 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.