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V SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <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: G.I.Trucking I Date of Testing: May 15,2006 <br /> Facility Address: 7611 S.Airport Way,Stockton,CA 95206 <br /> Facility Contact: IPhone: <br /> Date Local Agency Was Notified of Testing: May 10,2006 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: STOCKTON SERVICE STATION EQUIPMENT CO. INC. <br /> Technician Conducting Test: Eric Molgaard <br /> Credentialst: 0 CSLB Contractor (x)ICC Service Tech. 0 SWRCB Tank Tester 0 Other(Spec) <br /> License Number(s): ICC 5250200-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: (x)Hydrostatic 0 Vacuum :1 Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 DIESEL FUEL 2 3 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: (x)Direct Bury 0 Direct Bury 0 Direct Bury 0 Direct Bury <br /> ❑Contained in Sump 0 Contained in Sump 0 Contained in Sump 0 Contained in Sum <br /> Bucket Diameter: <br /> Bucket Depth: 16-1/2 inch <br /> Wait time between applying 5 minutes <br /> vacuum/water and start of test: <br /> Test Start Time(TO: 10:25 am <br /> Initial Reading(R,): 10-1/2 inch <br /> Test End Time(TF): 11:25 am <br /> Final Reading(RF): 10-1/2 inch <br /> Test Duration(TF—TO: 1 hour <br /> Change in Reading(RF-R,): -0- <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: (x)Pass '❑Fail 0 Pass ''❑Fail 0 Pass 0 Fail 0 Pass 0 Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <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: ErtC Nofgaaa.Ytt Date: May 15,2006 <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 />