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SWPCB,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 ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Stockton AASF Date of Testing: 10/23/09 <br /> Facility Address: 2000 Stimson RD Stockton CA.95206 <br /> Facility Contact: MSG Pica I Phone: 209-983-5331 <br /> p Date Local Agency Was Notified of Testing: 48 hr+ <br /> LName of Local Agency Inspector(if present during testing): Muniappa Naidu San Joaquin CO. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Tank Team inc, <br /> Technician Conducting Test: Hector Galindo <br /> Credentials': x CSLB Contractor x ICC Service Tech. 0 SWRCB Tank Tester -0 Other(Specify) <br /> License Number(s): 512835 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: x Hydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used: Incon is sts Equipment Resolution:.002" <br /> .......... <br /> Identify Spill Bucket(By Tank 1-15k 2 3 4 <br /> Number, Stored Product, <br /> — <br /> Bucket Installation Type: x Direct Bury Direct Bury 0 Direct Bury El Direct Bury <br /> -0 Contained in Sump 0 Contained in Sump 0 Contained in Sum <br /> Bucket Diameter: 12" 0 Contained in Sump <br /> Bucket Depth: 12" <br /> Wait time between applying '0 min <br /> vacuum/water and start of test: <br /> Test Start Time(Tr): 8:22 8:38 <br /> Initial Reading(Rj): 4.2382" 4.2382" <br /> Test End Time(TF): 8:37 8:53 <br /> Final Reading(RF): 4.2382" 4.2380" <br /> Test Duration(TF—Ti): 15 min 2 x <br /> Change in Reading(RF-Rj): .00001, .0002" <br /> Pass/Fail Threshold or .002" <br /> Criteria: <br /> Test Result: x Pass 0 Fail 0 Pass 0 Fail 0 Pass 0 Fail 0 Pass 0 Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-upfor failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby cert6 that all the Information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: t wc(�— Date:10/23/09 <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 />