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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 <br />printouts from tests (if applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br />Facility Name: City Of Stockton- Corp Yard Date of Testing: 4-18-13 <br />Facility Address: 1465 S Lincoln St, Stockton, Ca 95206 <br />Facility Contact: I Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): Stacy <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Henderson Maintenance Company <br />Technician Co <br />Credentials': [X] CSLB Contractor 1XI ICC Service Teck 0 SWRCB Tank Tester 9 *1her (Specify) <br />License Number(s): CSLB: 856771 ICC: XX4341042455 <br />Test Method Used: X Hydrostatic 0 Vacuum 0 Other <br />Test Equipment Used: <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 -Diesel <br />2-87 <br />3 <br />4 <br />Bucket Installation Type: <br />X Direct Bury <br />0 Contained in Sump <br />X Direct Bury <br />0 Contained in Sump <br />0 Direct Bury <br />0 Contained in Sump <br />0 Direct Bury <br />0 Contained in Sump <br />Bucket Diameter: <br />III, <br />III, <br />Bucket Depth: <br />17" <br />14 1/2" <br />Wait time between applying <br />vacuum/water and start of test: <br />2 mins <br />2 mins <br />Test Start Time (T): <br />9:20a <br />9:20a <br />Initial Reading (Rd: <br />15 3/4" <br />13 V2- <br />Test End Time (TF): <br />10:25a <br />10:25a <br />Final Reading (RF): <br />-1/81, <br />-1/81, <br />Test Duration (TF — TI): <br />Ihr 5mins <br />Ihr 5mins <br />Change in Reading (RF - R� : <br />1/8" <br />1/81, <br />Pass/Fail Threshold or <br />Criteria: <br />P <br />P <br />Test Result: <br />X Pass []Fail <br />X Pass []Fail <br />11 Pass 0 Fail <br />0 Pass []Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />Inspector said that an -1/8" drop is allowed in the amount of time. Confirmed it <br />was ok for me to Pass. <br />CERTIFICATION OF TECHNICLAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />Technician's Signature: <br />Date: q -1g. /3 <br />State laws and regulations do not currently require testing to be performed by a qualffied contractor. However, local requirements <br />