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e - e <br /> 9 <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: Bank of Stockton Date of Testing: 11-03-2009 <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: 10.26.2009 <br /> Name of Local Agency Inspector(if 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': F11 CSLB Contractor x ICC Service Tech. ❑ SWRCB Tank Tester Other(Spec) <br /> License Number(s): ICC 5250200 UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [x] Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Tape Equipment Resolution: 1/32" <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.)--I[ <br /> Bucket Installation Type: [X] Direct Bury ❑Direct Bury ❑ Direct Bury Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump Contained in Sum ❑Contained in Sum <br /> Bucket Diameter: 12 inch <br /> Bucket Depth: 17 inch _ <br /> Wait time between applying 5 minutes <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 8:40 a.m. <br /> Initial Reading(Rj): 1 inch from Top <br /> Test End Time(TF): 9:40 a.m. <br /> Final Reading(RF): 1 inch from Top <br /> Test Duration(TF—Tj): 1 hour <br /> Change in Reading(RF-Rj): -0- <br /> Pass/Fail Threshold or > 1/16 inch <br /> Criteria: <br /> Test Result: [X] Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail ❑ 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 /> 1 hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Eric Nolgaard Date: November 3,2009 <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 /> I <br />