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SWRCB, January 2006 Zli 11111111 111111 1 t I 1111l11111111is 1 i This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Country Club 76 1 Date of Testing: 12-6-07 Facility Address: 2575 Country Club Blvd. Stockton Facility Contact: Marie I Phone: 209 948-0575 Date Local Agency Was Notified of Testing : 11-20-07 Name of Local Agency Inspector (ifpresent during testing): Garret Backus 2. TESTING CONTRACTOR INFORMATION Company Name:_ BZ Service Station Maintenance Technician Conducting Test: James A. Williams Credentials': X CSLB Contractor X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) 9 License Number(s): 433159 5252274 1 CERTIFICATION OF TECBNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all o ' n contained in this report is true, accurate, and in full compliance with legal requirements. �1 Technician's Signature: Date: 12-6-07 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. 3. SPILL BUCKET TESTING INFORMATION Test Method Used: X Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: Beaker Identify Spill Bucket (By Tank 1 87 Number, Stored Product, etc. 2 91 Equipment Resolution: 3 DSL 0 4 Bucket Installation Type: ❑ Direct Bury X Contained in Sump ❑ Direct Bury X Contained in Sump ❑ Direct Bury X Contained in Sump ❑ Direct Bury ❑ Contained in Sum Bucket Diameter: 1 12 12 12 Bucket Depth: 16 16 16 Wait time between applying vacuum/water and start of test: 0 0 0 Test Start Time (Ti): 10:30 10:30 10:30 Initial Reading (Rj): 500 500 500 Test End Time (TF): 11:30 11:30 11:30 Final Reading (RF): 500 500 500 Test Duration (TF— Ti): 60 Min 60 Min 60 Min Change in Reading (RF- R,): 0 0 0 Pass/Fail Threshold or Criteria: 0 0 0 Test Result: X Pass ❑Fail' X Pass' Q Fail X Pass ❑Fait ❑Pass D;Fail Comments — (include information on repairs made prior to testing, and recommended follow-up forfailed tests) CERTIFICATION OF TECBNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all o ' n contained in this report is true, accurate, and in full compliance with legal requirements. �1 Technician's Signature: Date: 12-6-07 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.