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0 0 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <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: Stockton AASF I Date of Testing: 9/16/08 <br /> Facility Address: 2000 Stimson RD Stockton CA.95206 <br /> Facility Contact: MSG Pica I Phone: 209-983-5331 <br /> Date Local Agency Was Notified of Testing: 9/08 <br /> Name of Local Agency Inspector(if present during testing): Muniappa Naidu San Joaquin CO. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Tank Team inc, <br /> Technician Conducting Test: Hector Galindo <br /> Credentials: x CSLB Contractor x ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 512835 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: x Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used:Incon is sts Equipment Resolution:.002" <br /> Identify Spill Bucket(By Tank 1-15k 2 3 4 <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: x Direct Bury Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" <br /> Bucket Depth: 12" <br /> Wait time between applying 30 min <br /> vacuum/water and start of test: <br /> Test Start Time(TO: 8:23 8:38 <br /> Initial Reading(RI): 6.4704" 6.4699" <br /> Test End Time(TF): 8:38 8:54 <br /> Final Reading(RF): 6.4700" 6.4697" <br /> Test Duration(TF—T�: 15 mm 2 x <br /> Change in Reading(RF-Rq): .0004" .0002" <br /> Pass/Fail Threshold or 002„ <br /> Criteria: <br /> Test Result: x Pass ❑FOR ❑ Pass 0 Fail ❑ Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for ailed tests) <br /> CERTIFICATION OF TECEMCIAN 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 /> j f (�C(Ll <br /> Technician's signature: Date: Ot`t �► <br /> �0� <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 />