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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 for submittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name : CITY OF STOCKTON CORP YARD Date of Testing : 4-747 <br /> Facility Address : 1465 S LINCOLN ST STOCKTON CA <br /> Facility Contact: Phone : <br /> Date Local Agency Was Notified of Testing : 3 -27- 17 <br /> Name of Local Agency Inspector (tf present during testing) : <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name : AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) 744-0112 Fax : (209) 744-0116 <br /> Technician Conducting Test: DED Stearns ❑ Zane A . Nimmo ® David A. Winkler ❑ Felix G. Ramirez <br /> 8184188 5263322-UT 5263373 -UT 5273934-UT <br /> Credentials : ® ICC Service Tech . ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used : ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used : h20 and tape measure Equipment Resolution : 1 / 16 <br /> Identify Spill Bucket (By Tank 1 1 87 3 DSL <br /> Number, Stored Product, etc) <br /> ® Direct Bury ® Direct Bury <br /> Bucket Installation Type : E] Contained in <br /> E] Contained in Sump Sum <br /> Bucket Diameter : 11 11 <br /> Bucket Depth : 15 17 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time (Ti) : 937 937 <br /> Initial Reading (Rr) : 14 16 <br /> Test End Time (TF) : 937 937 <br /> Final Reading (RF) : 14 16 <br /> Test Duration (TF — Ti) : IHR 1 HR <br /> Change in Reading (RF - RI) : 0 0 <br /> Pass/Fail Threshold or 1 / 16 1 / 16 <br /> Criteria : <br /> Test Result: PASS PASS <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 : T� Date 44- 17 <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 />