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F-1 <br />C <br />i i I0 11111,111 ON! 11111 <br />1 131 1 1 <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 />Facility Name: ECONO GAS Date of Testing: 09-17-10 <br />Facility Address: 880 E. VICTOR ROAD, LODI <br />Facility Contact: MR. SINGH T Phone: 209-369-0958 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (rfpresent during testing): ARIS CACAPIT <br />Company Name: BZ Service Station Maintenance <br />Technician Conducting Test: JERAMY CUMMINS <br />Credentials': X CSLB Contractor X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 433159 <br />Test Method Used: X Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE Equipment Resolution: ZERO <br />Zu tri...,t it ..,.. .+; sR.{.5j.N^+x.A045'.;. <br />Identify Spill Bucket (By Tank 1 87 <br />Number, Stored Product, etc. <br />2 3 <br />4 <br />Bucket Installation Type: X Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury ❑ Direct Bury <br />❑ Contained in Sump ❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: 12" <br />Bucket Depth: 13" <br />Wait time between applying 0 <br />vacuum/water and start of test: <br />Test Start Time (TI): 3:40 <br />Initial Reading (RI): 12" <br />Test End Time (TF): 4:40 <br />Final Reading (RF): g" <br />Test Duration (TF — TI): 1 HOUR <br />Change in Reading (RF —Rj): 4" <br />Pass/Fail Threshold or 0 <br />Criteria: <br />Test Result: ❑ Pass X Fail <br />❑ Pass ❑ Fail ❑Pass ❑Fail <br />❑Pass ❑Fail <br />uomments — (include information on repairs made prior to testing and recommended follow-up for failed tests) <br />Basket split (a, bellows and leaking <br />- TECHNICIAN: JERAMY CUMMINS <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certj& that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: <br />Date: 09/17/10 <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 />