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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: Bank of Stockton I Date of Testing: 11/19/2007 <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: 11/14/2007 <br /> Name of Local Agency Inspector(fpresent 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': 1 ❑CSLB Contractor CC Service Tech. ❑SWRCB Tank Tester Other(Spec) <br /> License Number(s): ICC 525020OUT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [x] Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: TMS Equipment Resolution: 1/32" <br /> Identify Spill Bucket(By Tank 1 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 inch <br /> Bucket Depth: 18 inch <br /> Wait time between applying <br /> vacuum/water and start of test: 5 minutes <br /> Test Start Time(TI): 9:30 a.m. <br /> Initial Reading(Ri): 10 inch <br /> Test End Time(TF): 10:30 a.m. <br /> Final Reading(RF): 10 inch <br /> Test Duration(TF—TI): 1 hour <br /> Change in Reading(RF-RI): -0- <br /> Pass/Fail Threshold or Less than 1/16 inch <br /> Criteria: <br /> Test Result: [X] Pass ❑Fail ❑ Pass ❑Fait ❑ 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 /> 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: Eric-VoCgaard Date:November 19,2007 <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 />