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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 /> printoutsfrom tests(if applicab le),should be provided to thefacility own er/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Sprint Stockton I Date of Testing: 10-27-17 <br /> Facility Address: 3807 Coronado Ave <br /> Facility Contact: Ken 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 IH <br /> Credentials': x CSLB Contractor x ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 708231,8195227 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: x Hydrostatic ❑Vacuum 0 Other <br /> Test Equipment Used:Incon Equipment Resolution:+-0.002 <br /> Identify Spill Bucket(By Tank Diesel 2 3 4 <br /> Number,Stored Product,etc) <br /> Bucket Installation Type: x Direct Bury ❑Direct Bury ❑Direct Bury 11 Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump D Contained in Sump 0 Contained in Sum <br /> Bucket Diameter: 12" <br /> Bucket Depth: 12" <br /> Wait time between applying 20 min <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:00 <br /> Initial Reading(R,): 1"down from top <br /> Test End Time(TF): 10:00 <br /> Final Reading(Rp): 1"down from top <br /> Test Duration(TF—Tj): 1 hr <br /> Change in Reading(RF-Its): 0 change <br /> Pass/Fail Threshold or O loss <br /> Criteria: <br /> Test Result: X Pass ❑Fail ❑ Pass ❑Fall ❑ Pass ❑Fall ❑ Pass ❑Fail <br /> COMMerits—(include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> Test water was deemed non hazardous and removed from site for futue, testine <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: 1111 " / Date:-10-27-17 <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 />