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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: Unified Grocers Date of Testing: 2-18-09 <br />Facility Address: 1990 Piccoli Rd. Stockton, Ca. <br />Facility Contact: Fleet Manager Phone: 209-931-1990 <br />Date Local Agency Was Notified of Testing :2-13-09 <br />Name of Local Agency Inspector (tfpresent during testing): Jeff Wong <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: A & J Environmental <br />Technician Conducting Test: Asa Cosby <br />Credentials': X CSLB Contractor X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s):653381 525-2300 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: X Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />ldiesel <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />X 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 Sum <br />Bucket Diameter: <br />12" <br />Bucket Depth: <br />16" <br />Wait time between applying <br />vacuum/water and start of test: <br />30 min. <br />Test Start Time (TI): <br />0900 <br />Initial Reading (RI): <br />15.5" (full) <br />Test End Time (TF): <br />10:00 <br />Final Reading (RF): <br />15.5 (full) <br />Test Duration (TF — TI): <br />1 hour <br />Change in Reading (RF - RI): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />Test Result: <br />X Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ 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 th 'nformation contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: Date: C-4 " <br />' State laws and regulations do not currently require testing to be p orrned by a qualified contractor. However, local requirements <br />