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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: Bank of Stockton I Date of Testing: 11/22/2006 <br /> Facility Address: 1941 Lockheed Court,Stockton,CA <br /> Facility Contact: Norm White Phone: 209.483.0257 <br /> Date Local Agency Was Notified of Testing: 11/13/2006 <br /> Name of Local Agency Inspector(f present during testing): Muniappa Naidu <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: STOCKTON SERVICE STATION EQUIPMENT CO.INC. <br /> Technician Conducting Test: Eric Molgaard <br /> Credentials': I ❑CSLB Contractor CC Service Tech. ❑SWRCB Tank Tester Other(Spec) <br /> License Number(s): ICC 525020OUT <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 1 2 3 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: X Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12 inch <br /> Bucket Depth: 18 inch <br /> Wait time between applying 5 minutes <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:00 a.m. <br /> Initial Reading(RI): 10-1/4 inch <br /> Test End Time(TF): 10:00 a.m. <br /> Final Reading(RF): 10-1/4 inch <br /> Test Duration(TF—TI): 1 hour <br /> Change in Reading(RF-RI): -0- <br /> Pass/Fail Threshold or Less than 1/16 inch <br /> Criteria: <br /> Te t,1,ii t „Pais 1 azl Gl,l"ass ©earl." t bass CI Fail C °I" ss,:. ❑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: Eric MoCgaard Date: November 22,2006 <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 />