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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(f applicable),should be provided to the facility owner/operator forsubmttal to the local aegulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Names: Bank Of Stockton Date of Testing: 9/25/2017 <br /> Facility Address: 1941 E Lockheed Hanger#3 Stockton Ca 95215 <br /> Facility Contact: Norman White Phone: 209 483-0257 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ELITE IV CONTRACTORS <br /> Technician Conducting Test: Joe Bartholdi <br /> Credentials: CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic Vacuum Other <br /> Test]Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 Jet Fuel 2 3 4 <br /> Number, Stored Product, etc.) <br /> X Direct Bury Direct Bury Direct Bury Direct Bury <br /> Bucket Installation Type: Contained in Sump Contained in Sump Contained in Sump Contained in Sum <br /> Bucket Diameter: 11 <br /> Bucket Depth: 19 <br /> Wait time between applying 5min <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 9:30 <br /> Initial Reading(RI): 16.5 <br /> Test End Time(TF): 10:30 <br /> Final Reading(RF): 16.5 <br /> Test Duration(TF—Ti): i hr <br /> Change in Reading(RF-Ri): [Pass Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: X Pass ❑Fall Pass L Fall Pass ❑Fall ❑ Pass ❑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: Date: 9/25/2017 <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 />