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0 <br /> 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 con7pleted form and <br /> printouts from tests (rf 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: 11/8/2013 <br /> Facility Address: 3807 Coronado Ave <br /> Facility Contact: Doye Phone: 217-663-9440 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): Garrett Backus <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jauregui&Culver inc <br /> Technician Conducting Test: Peter Jauregui III <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 ❑Other <br /> Test Equipment Used: Water and Tape Measure Equipment Resolution: O loss <br /> Identify Spill Bucket(By Tank Diesel 2 <br /> Number,Stored Product, etc) _- <br /> Bucket Installation Type: x Direct Bury ❑Direct Bury ❑Direct Bury U Direct Bury <br /> LIContained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sung <br /> Bucket Diameter: 11 '/2" <br /> Bucket Depth: 11 '/a ' <br /> Wait time between applying 20 min <br /> vacuum/water and start of test: <br /> Test Start Time (T,): 8:54 <br /> Initial Reading(RI): 11/2"Down From Top <br /> Test End Time(TF): 9:54 <br /> Final Reading(RF): 2'/z"Down From Top <br /> Test Duration(TF–TI): I hr <br /> Change in Reading(RI;-RI): 0 change <br /> Pass/Fail Threshold or 0 loss <br /> Criteria; <br /> Test Result: X Pass . 7 Fail C7 Pass ''U Tail ❑ Pass ❑Fail ❑ Passe ❑Fail <br /> 1.Comments– (include ig urination on repairs made prior to testing, and 7�ecamniended follow-u for failed tests) <br /> Test water was deemed non hazardous and removed from site for future testinp. <br /> k <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. i[ <br /> Technician's Signature: Date:_11/20/2013 <br /> 1 State Iaws and regulations do currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />