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- • i <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 completed form and <br /> printouts from tests(if applicable),should be provided to the facility ownerloperator,for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Sprint Stockton ate of Testing: 11/18/2010 <br /> Facility Address: 3807 Coronado Ave <br /> Facility Contact: Ken Carr hone: 209 993-8205 <br /> Date Local Agency Was Notified of Testing:Oct <br /> [Name of Local Agency Inspector(f present during testing):Garrett Backus <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: LeMesnager Engineering <br /> Technician Conducting Test Rene LeMesnager <br /> Credentials: ✓CSLB Contractor ✓ ICC Service Tech. S WRCB Tank Tester Other(Specify) <br /> License Number(s):203029 <br /> 3. SPILT.BUCKET TESTING INFORMATION <br /> Test Method Used: ✓Hydrostatic Vacuum Other(Spec) <br /> Test Equipment Used: 1 hr visual JEquipment Resolution: <br /> Identify Spill Bucket(By Tank Diesel 2 3 <br /> Number,Stored Product, etc, <br /> Bucket Installation Type: J Direct Bury Direct Bucy ®Direct Bury (] Direct Bury <br /> Contained in Sump Contained in Sump Contained in Sump ® Contained in Sump <br /> Bucket Diameter: 14" <br /> Bucket Depth: 12" <br /> Wait time between applying 15 min <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): :15 AM <br /> Initial Reading(Ri): 1-1/2"below top of ring <br /> Test End Time(TF): 10:15 AM <br /> Final Reading(RF): 1-1/2"below top of ring <br /> Test Duration(TF—Ti): 1 hr <br /> Change in Reading(RF-Ri) one <br /> ass/Fail Threshold or Criteria: o loss <br /> est Result: I ✓ Pass Fall [] Pass Q Fail [] Pass Fail Pass Fall <br /> Comments—(include information on repairs made prior to testing,and recommended follow-up for failed tests) <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 fall compliance with legal requirements <br /> r <br /> Technician's Signature: Date: 11/18/2010 <br />