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SWRCB, January 2002 Page _t__ of lf
Secondary Containment Testing Report Form
This form is intendedfor use by contractors performingperiodic testing ofUSTsecondary containment systems. Use the
appropriate pages ofthis form to report resultsfor all components tested The completedform, written test procedures, and
printoutsfrom tests (fapplicable), should be provided to thefacility owner /operatorfor submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: WESTCHESTER MOBIL Date ofTesting: 1/27/12
Facility Address: 3200 F STREET, BAKERSFIELD
Facility Contact: Phone:
Date Local Agency Was Notified ofTesting:
Name ofLocal Agency Inspector (ifpresent during testing): ERNIE
2. TESTING CONTRACTOR INFORMATION
Company Name: Rich Environmental
Technician Conducting Test: RICH PHILLIPS
Credentials: X CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester
License Type: C61/1340 A HAZ
M
License Number. 809850
Manufacturer
Manufacturer Training
Component(s) Date Training Expires
INCON TS -STS 6/11/2012
3. SUMMARY OF TEST RESULTS
Component Component MMMMM"MiR
I VAPOR BUCKET
raoo nnor..;
000 a000
onoo 000
0000 n000
oo o iaaoo
nor.o 0000
nnor nnoo
000 o000
0000 0000
If hydrostatic testing was performed, describe what was done with the water after completion of tests:
CERTIFICATION OF TECHNI lAN RESPONSIBLE FOR CONDUCTING THIS TESTING
To the best of my knowledge, thefacts state this document are accurate and infull compliance with legal requirements
Technician's Signature: Date: 1/27/12
10
LA D %-I -, -5
SWRCB January 2006
Spill Bucket Testing Report Form
Thisform is intendedfor use by contractors performing annual testing ofUSTspill containment structures. The completedform and
printoutsfrom tests (tfapplicable), should be provided to thefacility owner /operatorfor submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: WESTCHESTER MOBIL Date ofTesting: 1/27/12
Facility Address: 3200 F STREET, BAKERSFIELD
Facility Contact: Phone:
Date Local Agency Was Notified of Testing:
Name of Local Agency Inspector (rfpresent during testing): ERNIE
2. TESTING CONTRACTOR INFORMATION
Company Name: RICH ENVIRONMENTAL
Technician Conducting Test: RICH PHILLIPS
Credentials': CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other (Specie)
License Number(s): 1035169 -UT
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: X Hydrostatic Vacuum Other
Test Equipment Used: Equipment Resolution:
Identify Spill Bucket (By Tank
Number, Stored Product, etc)
1
91 VAPOR
2 3 4
Bucket Installation Type: Direct Bury
X Contained in Sump
Direct Bury
Contained in Sump
Direct Bury
Contained in Sump
Direct Bury
Contained in Sum
Bucket Diameter. 12"
Bucket Depth: 14"
Wait time between applying
vacuum/water and start of test: 30 MIN
Test Start Time (Ti): 1:10
Initial Reading (RO: 14"
Test End Time (TF): 2:10
Final Reading (RF): 14"
Test Duration (TF — Tj): 1 -HOUR
Change in Reading (RF -Rj): 0.00
Pass/Fail Threshold or
Criteria: 0,00
Test Result: X Pass Fail Pass Fail Pass Fail Pass Fail
COMMentS — (include information on repairs made prior to testing, and recommendedfollow -upforfailed tests)
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
I hereby certify that allthe information coat fined in this report is true, accurate, and infull compliance with legal requirements.
Technician's Signature: Date: 1/27/12
I
State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements
may be more stringent