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SWRCB, January 2006 <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from <br />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: CHP Stockton I Date of Testing: 2-26-10 <br />Facility Address: 3330 N. Ad Art Rd. Stockton, CA 95208 <br />Facility Contact: Linh Ngo Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (f present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: CALIFORNIA HAZARDOUS, INC. <br />Technician Conducting Test: Brian Halfwassen <br />Credentials': ® CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 734854 ICC#: 5006847 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Visual <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />87 Fill <br />Bucket Installation Type: <br />❑ Direct Bury <br />® Contained in Sump <br />❑ Direct Bury <br />Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />III, <br />Bucket Depth: <br />12" <br />Wait time between applying <br />vacuum/water and start of test: <br />15 Minutes <br />Test Start Time (TI): <br />2:15pm <br />Initial Reading (RI): <br />10.5„ <br />Test End Time (TF): <br />3:15pm <br />Final Reading (RF): <br />10.5” <br />Test Duration (TF — TI): <br />1 Hour <br />Change in Reading (RF - RI): <br />0 <br />Pass/Fail Threshold or Criteria: <br />0 <br />Test Result: <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />Vapor bucket not required to be tested. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information,on�contained inthisreport is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: �'�"~ -g— ---- Date 2-26-10 <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more <br />stringent. <br />