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SpAiucket Tesfinge r <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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: United Parcel Service Date of Testing: 6-15-2009 <br /> Facility Address: 1532 North Broadway-Stockton,CA 95205 <br /> Facility Contact: Herman Meyer-Plant Engineering I Phone: (916)373-4001 <br /> Date Local Agency Was Notified of Testing: 5-29-2009 <br /> Name of Local Agency Inspector(afpresent during testing): Ray Von Flue-San Joaquin County E.H.D. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: PETRO-TECHZ Environmental Services <br /> Technician Conducting Test: Dan Zeman <br /> Credentials': ❑CSLB Contractor X ICC Service Tech. X SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): ICC Service Technician No.:5243781-UT-CA SWRCB Tank Tester License No.: 1535 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic Vacuum Other: <br /> Test Equipment Used: Tape Measure-Lake Test Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 4 <br /> Number, Stored Product, etc. s L 7 <br /> Bucket Installation Type: Direct Bury <br /> Bucket Diameter: 11" <br /> Bucket Depth: 13" <br /> Wait time between applying 15 Minutes <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 9:22 am <br /> Initial Reading(Rj): 13" <br /> Test End Time(TF): 10:22 am <br /> Final Reading(RF): 13" <br /> Test Duration(TF-Ti): 60 Minutes <br /> Change in Reading(RF-RI): 0.00 <br /> Pass/Fail Threshold or y4"in a 24 Hr.Period <br /> Criteria: <br /> Test Result: Pass <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: Date:June 15,2009 <br /> P.—Gofc <br />