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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 farm and <br /> printouts from tests(f 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—Hanger 3 Date of Testing: 10/20/15 <br /> Facility Address: 1941 E.Lockheed Ct.Stockton CA 95206 <br /> Facility Contact"Norman White Phone:209483-0257 <br /> Date Local Agency Was Notified of Testing 10/2/15 <br /> Name of Local Agency Inspector(ifpresent during testing): Elena Manzo <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(Spec) <br /> License Number(s):B36852 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic Vacuum Other <br /> Test Equipment Used:Water Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number,Stored Product,etc.) JET FUEL <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> Contained in Sump Contained in Sump Contained in Sump Contained in Sump <br /> Bucket Diameter. 10" <br /> Bucket Depth: 19%11 <br /> Wait time between applying I hour <br /> vacuum/water and start of test: _ <br /> Test Start Time(Ti): 10:00 <br /> Initial Reading(Ri): 18" <br /> Test End Time(TF): 11:00 <br /> Final Reading(RF): 18" <br /> Test Duration(TF—Ti): ENVIRIMMMAI <br /> Change in Reading(RF-Rj): HFAIT ni=paQTKprKrr <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: Psis ©Fail n Pass 0 Fall 0 Pass 0 Fail 1 0 Pass 0 Fail <br /> Comments—(include information on repairs made prior to testing,and recommended follow-up forfailed tests) <br /> Left test water on site in Hazmat drum <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby ceiWfy that all the in mad con fined in this report is true,accurate,and in full compliance with legal requirements <br /> Technician's Signature: Date: U at) f <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 />