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SWRCB,January 2006 <br /> Spill Bucket Testing Report For <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. 11e completed form and <br /> printouts fi-om 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 Date of Testing: 10/10/2016 <br /> Facility Address: 1941 Lockheed Ct Stockton Ca 95206 <br /> Facility Contact: Norman White 209488-0257 <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): 1001331A-HAZ <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 A 2 3 4 <br /> Number,Stored Product, etc.) <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> Contained in Sump Contained in SuLnp Contained in Sump Contained in Sum <br /> Bucket Diameter: 14 <br /> Bucket Depth: 20' <br /> Wait time between applying lm, <br /> vacuum/water and start of test: <br /> Test Start Time(TO: 9:30 <br /> Initial Reading(Rj): 19' tA <br /> ,u <br /> Test End Time(TF): 10:30 NOV t <br /> Final Reading(RF): 19' <br /> Test Duration(TF—TI): 1 hr <br /> Change in Reading(RF-Rj): 0 V ' ' t`'' ENT <br /> `` e <br /> Pass/Fail Threshold or Pass <br /> DEF <br /> Criteria: <br /> Test Result: (X) ,Pass '0 Fail {X) Pass; OF (X) Pass ®Fail (2) Pass D 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: 10/10/2016 <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 />