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S WRCB,January 2002 Page_of <br /> Secondary Containment Testing Report Form <br /> This farm is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this farm to report results for all components tested The completed form, written test procedures, 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: Sprint Stockton Date of Testing: 10-27-17 <br /> Facility Address: 3807 Coronado Ave. Stockton 95204 <br /> Facility Contact: Frank Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jauregui&Culver inc <br /> Technician Conducting Test: Peter Jauregui BI <br /> Credentials: X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,B,C21,Haz License Number:708231 <br /> Manufacturer Trainin¢ <br /> Manufacturer Component(s) Date Training Expires <br /> Incon 7602133701 5-22-19 <br /> ICC 8195227 6-2-19 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Comonent Pass Fail Not Repairs <br /> p <br /> Tested Made Tested Made <br /> Diesel sump UST X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill bucket X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Diesel annular UST ❑ ❑ X ❑ ❑ ❑. ❑ ❑ <br /> Supply Piping X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Return piping X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ [1— <br /> F] <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ I ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Test Water was deemed non-hazardous and removed at the time of test to be used <br /> On Future tests. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: ��'2fi Date:_10-27-17 <br />