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2 <br />11 <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 (f 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 I Date of Testing: March 08, 2006 <br />Facility Address: 1465 S. Lincoln Street, Stockton, CA 95206 <br />Facility Contact: Phil Burnside Phone: (209) 937-7417 <br />Date Local Agency Was Notified of Testing: 2/22/2006 <br />Name of Local Agency Inspector (fpresent during testing): <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 ❑ Other (Spec) <br />License Number(s): ICC 5250200 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ❑ Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />1 <br />2 <br />3 <br />7.: <br />4 <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 />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />Initial Reading (Rj): <br />Test End Time (TF): <br />Final Reading (RF): <br />Test Duration (TF — TI): <br />Change in Reading (RF - Rj): <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />4 Pass 01 Fail <br />"❑'Pass' o Fail <br />0 Pass ❑ Fail <br />❑ Pass ❑Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />_SPILL BUCKET TESTING DONE 12/2005 AS PART OF SB -989 TESTING <br />DID NOT TEST AS PER INSPECTORS INSTRUCTIONS <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: <br />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 />