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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 owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: City of Stockton, Corporation Yard Date of Testing: March 6, 2008 <br />Facility Address: 1465 S. Lincoln Street, Stockton, CA 95206 <br />Facility Contact: Phil Burnside I Phone: 209-937-7417 <br />Date Local Agency Was Notified of Testing: February 26, 2008 <br />Name of Local Agency Inspector (f present during testing): Ray Von Flue <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: STOCKTON SERVICE STATION EQUIPMENT CO. INC. <br />Technician Conducting Test: Eric Molgaard <br />Credentials': ❑ CSLB Contractor x ICC Service Tech. ❑ SWRCB Tank Tester J Other (Spec) <br />License Number(s): <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: x Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />1 <br />Unleaded <br />2 <br />Diesel <br />3 <br />4 <br />Bucket Installation Type: <br />X Direct Bury <br />❑ Contained in Sump <br />X 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 inch <br />12 inch <br />Bucket Depth: <br />14-1/2 inch <br />17 inch <br />Wait time between applying <br />vacuum/water and start of test: <br />2 minutes <br />5 minutes <br />Test Start Time (Ti): <br />11:10 am <br />11:10 am <br />Initial Reading (RI): <br />13-1/8 inch <br />16 inch <br />Test End Time (TF): <br />12:11 p.m. <br />12:10 p.m. <br />Final Reading (RF): <br />13-1/8 inch <br />16 inch <br />Test Duration (TF — Tt): <br />1:01 Hours <br />1:00 Hour <br />Change in Reading (RF - Rt): <br />-0- <br />-0- <br />Pass/Fail Threshold or <br />Criteria: <br />Less than 1/16 drop <br />Less titan 1/16 drop <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 />WATER LEFT ON SITE IN DRUM <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: &C 01fdo atd <br />Date: March 6, 2008 <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 />