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S WRCB,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 completedform and <br /> printouts from tests(f applicable),should be provided to thefacility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION i <br /> Facility Name: Sprint Stockton Date of Testing: 11/8/2012 <br /> Facility Address: 3807 Coronado Ave <br /> Facility Contact: Doye Phone: 2I7-663-9440 <br /> Date Local Agency Was Notified of Testing: 1 <br /> Name of Local Agency Inspector((present during testing): Garrett Backus <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jauregui&Culver inc <br /> Technician Conducting Test: Peter Jauregui M <br /> Credentials': x CSLB Contractor x ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 70823 t,5315297 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: x Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Nater and Tape Measure Equipment Resolution: 0 Losse <br /> Identify Spill Bucket(Ry Tank Diesel 2 3 q <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: x Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sum2 ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 11 '/2" <br /> Bucket Depth: 11 '/2" <br /> Wait time between applying 20 min <br /> vacuum/water and start oftest; <br /> Test Start Time(Ti): 9:22 <br /> Initial Reading(Rr): I V Down From Top <br /> Test End Time(TF): 10:22 <br /> Final Reading(RF): 2 `Ja"Down From Top <br /> Test Duration(TF—Tj: 1 hr <br /> Change in Reading(RF-RO: 0 change <br /> Pass/Fail Threshold or <br /> Criteria: 0 toss <br /> Fest Result ti ❑ )'ass' K Baal ❑ ass fl Fac ? p rPeiss ❑Fail i Pass ❑Fail t <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> Test water was deemed nen llazardous and removed from site for future testin)-_ <br /> S ill Bucket Failed . Relacement will be installed and tested. <br /> i <br /> I <br /> i <br /> CERTIFICATION OF'TECHNICIAN RESPONSHILE FOR CONDUCTING THIS TESTING E <br /> I hereby certo that all the information contained in this report is trite,accurate,and in full compliance with legal requirements. G <br /> Technician's Signature: Date: 11/28/2012 <br /> 'State laws and regulations d of currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br /> i <br />