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s <br /> S WRCB January 2006 � <br /> Spill Bucket Testing Report Form <br /> This farm is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(fapplicable),should be provided to the facility owner/operator far submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Sprint Stockton Date of Testing: 11/8/2012 j <br /> Facility Address: 3807 Coronado Ave i <br /> Facility Contact: Doye Phone: 217-663-9440 <br /> Date Local Agency Was Notified of Testing: j <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: Deter Jauregui III <br /> Credentials: x CSLB Contractor x ICC Service Tech. ❑ SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 708231,5315297 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: x Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used:Water and Tape Measure Equipment Resolution:0 Loss <br /> Identify Spill Bucket(By Tank Diesel 2 3 4 <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: x Direct Bury Q Direct Bury ❑Direct Bury 0 Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 11 l/» <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: 20 mm <br /> Test Start Time(T,): 9:22 <br /> Initial Reading(Ri): 1 '/4"Down From Top <br /> Test End Time(TF): 10:22 <br /> Final Reading(RF): 2 %4"Down From Top <br /> Test Duration(TF—T,): 1 hr <br /> I <br /> Change in Reading(RF-RO: 0 change <br /> Pass/Fail Threshold or <br /> Criteria: O loss <br /> het Result ❑ ]Pass2Fail f7 )lyas t� aii> 17 Pass Q Fail Q :Pass d Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-u for failed tests) <br /> Test water was de=!Qdnon hazardous n removedrempyed from site for future testing. <br /> Spill Bucket Failed . Replacement will be installed and tested. <br /> i <br /> f <br /> r <br /> i <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby cerf6fy that all the information contained In this report is true,accurate,and in full compliance with legal requirements. � <br /> i <br /> Technician's Signature: v Date: 11/28/2012 <br /> State laws and regulations d of currently require testing to be performed by a qualified contractor.However,Iocal requirements <br /> may be more stringent. <br />