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ft <br /> f SWRCB,January 2006 <br /> Spin 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(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Bank of Stockton I Date of Testing: 11-02-2010 <br /> Facility Address: 1941 Lockheed Court,Stockton,CA <br /> Facility Contact: Norm White Phone: 209.483.0257 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(f present during testing): Muniappa Naidu <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: STOCKTON SERVICE STATION EQUIPMENT CO. INC. <br /> Technician Conducting Test: Eric Molgaard <br /> Credentials': 0 CSLB Contractor ICC Service Tech. 0 SWRCB Tank Tester Other(Spec) <br /> License Number(s): ICC 52050200-U1; <br /> b ti, <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [xi Hydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used: tape Equipment Resolution: 1/32" <br /> Identify Spill Bucket(By Tank 1 jet fuel 2 retest 3 4 <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: [X] Direct Bury 0 Direct Bury 0 Direct Bury 0 Direct Bury <br /> ❑Contained in Sum 0 Contained in Sump 0 Contained in Sum 0 Contained in Sum <br /> Bucket Diameter: 12in same <br /> Bucket Depth: 20in same <br /> Wait time between applying 1 min 3 min <br /> vacuum/water and start of test: <br /> Test Start Time(T°): 9:10 am 10:30 <br /> Initial Reading(R°): 18'/:in 18'/2 in <br /> Test End Time(TF): 10:10 am 11:30 <br /> Final Reading(RF): 17'/:in 18'/:in <br /> Test Duration(TF—T°): 1 Hr 1 Hr <br /> Change in Reading(RF-R°): - 1 in 0 <br /> Pass/Fail Threshold or 1/16 1/16 in <br /> Criteria: <br /> Test Result: [ ] Pass X Fail X Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail <br /> _Comments—(include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> Shill bucket failed first test replaced O Rinl? under fill adapter and retested bucket <br /> Bucket passed the retest see solum 2 <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: 11/02/2010 <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 />