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0 <br />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 owner/operator for submittal to the local regulatory agency. <br />Facility Name: City Of Stockton — Corp Yard Date of Testing: 4-18-12 <br />Facility Address: 1465 E. Lincoln St Stockton, Ca <br />Facility Contact: Maria Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (zfpresent during testing): Stacy Riveria <br />Company Name: Henderson Maintenance Company <br />Technician Conducting Test: Charles Ferrucci <br />Credentials': ❑ CSLB Contractor 8 ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 5323096 -UT <br />"Emof /-11i Cowl <br />Test Method Used: ❑ Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Water, <br />Tape Measure, Stop Watch <br />Equipment Resolution: 1/16" <br />�., ., <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />�� . <br />1 DSL <br />287 <br />3 <br />„y c... umz <br />4 <br />Bucket Installation Type: <br />E Direct Bury <br />❑ Contained in Sump <br />E Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />12 <br />12 <br />Bucket Depth: <br />16 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />0918 <br />0918 <br />Initial Reading (RI): <br />157/8 <br />13 1/2 <br />Test End Time (TF): <br />1018 <br />1018 <br />Final Reading (RF): <br />157/8 <br />131/2 <br />Test Duration (TF— TI): <br />I HR <br />1 HR <br />Change in Reading (RF- RI): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />Test Result: <br />X Pass ❑ Fail <br />X 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 />CERTIFICATION O HN AN RESPONSIBLE FOR CONDUCTING THIS TE TNG <br />I hereby certify that all the in ma ' n port is true, accurate, and in full compliant i legal requirements. <br />Technician's Signature: Date: <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 />