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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intendedfor use by contractors performing annual testing of USTspill containment structures. The completedform 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: 11/6/2015 <br /> Facility Address: 3807 Coronado Ave <br /> Facility Contact: Doye Phone: 217-663-9440 D <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(ifpresent during <br /> BE6 08 2615 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jauregui&Culver inc ENVIR01AL <br /> Technician Conducting Test: Peter Jauregui III Tl,t �r <br /> Credentials: x CSLB Contractor x ICC Service Tech. SWRCB Tank Tester 7 Other(Specify) <br /> License Number(s): 708231,8195227 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: x Hydrostatic Vacuum fl 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 7 Direct Bury ❑Direct Bury Direct Bury <br /> ❑Contained in Sump Contained in Sump ❑Contained in Sump 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,): I"down from top <br /> Test End Time(Tr): 10:00 <br /> Final Reading(Rr): 1"down from top <br /> Test Duration(Tr—T,): 1 hr <br /> Change in Reading(RF-R,): 0 change <br /> Pass/Fail Threshold or 0 loss <br /> Criteria: <br /> Test Result: X Pass ❑Fail D Pass ❑Fail ❑ Pass D Fail ❑ Pass ❑Fail <br /> Comments—(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 future testiniz. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> /hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date:_I1-6-15 <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 />