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Ll <br />9 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: BOYETT PETROLEUM #98 - H & M MARKET Date of Testing: JULY 31, 2007 <br />Facility Address: 2501 E. JACKSON AVE, ESCALON, CA 95320 <br />Facility Contact: ROHDA HENRY I Phone: 209-549-5612 <br />Date Local Agency Was Notified of Testing: JULY 17, 2007 <br />Name of Local Agency Inspector (fpresent during testing): M. NAIDU <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 (Spec) <br />License Number(s): 803705 (CSLB Contractor) -- 1048103 -UT (ICC Service Tech.) -- 90-1200 (SWRCB Tank Tester) <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other (Spec) <br />Test Equipment Used: <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) REGULAR <br />SUPER <br />DIESEL <br />Bucket Installation Type: ® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: 11.00" <br />11.00" <br />13.00" <br />Bucket Depth: 14.75" <br />15.25" <br />21.00" <br />Wait time between applying 0 <br />vacuum/water and start of test: <br />0 <br />0 <br />Test Start Time (Ti): 9:00 AM <br />9:00 AM <br />9:00 AM <br />Initial Reading (Rt): 14.75" <br />15.25" <br />21.00" <br />Test End Time (TF): 10:00 AM <br />10:00 AM <br />10:00 AM <br />Final Reading (RF): 14.75" <br />15.25" <br />21.00" <br />Test Duration (TF — TI):1 HOUR <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - RI): 0 <br />0 <br />0 <br />Pass/Fail Threshold or Criteria: <br />TestResait. `': Pass ❑Fail ` <br />®Pass E] Fail <br />®'Pass ❑Fail <br />❑Pass E] 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 />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; `�Jc� <`"% Date: JULY 31, 2007 <br />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 />