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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. 7&e completed form 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 Date ofTesting:l 1/26/2007 <br /> Facility Address: 3807 Coronado Ave.,Stockton,CA 95204 <br /> Facility Contact: John McCollister Phone: 209-937-5$00 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): Garrett Backus <br /> 2. TESTING CONTRACTOR INFOR-NIA'CION <br /> Company Name: LeMesnager Engineering; <br /> Technician Conducting Test Rene LeMesanger <br /> Credentials': X CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number(s):203029 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic Vacuum -Other <br /> Test Equipment Used: Visual I hr test Equipment Resolution: <br /> Identify Spill Bucket(By Tani: lDiesel 2 3 4 <br /> Number, Stared Product, etc.) <br /> X Direct Bury Direct Bury _'Direct Bury -j Direct Bury <br /> Bucket Installation Type: Contained in Sum i l Contained in Sum Contained in Sum E Contained in Sum <br /> Bucket Diameter: 12" <br /> Bucket Depth: 15" <br /> Wait time between applying 15 min <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 10:30 <br /> Initial Reading(R,): 12.5" <br /> Test End Time(TF): 12:00 <br /> Final Reading(RF): 12.5" <br /> Test Duration(TF—T,): 1 lir. <br /> Change in Reading(RF-Ri): 0 <br /> Pass/Fail Threshold or 0-loss <br /> Criteria:. <br /> Test Result: X Pass ❑Fail El Pass 11 Fa <br /> ❑ Pass ❑Fail ❑ Pass ❑ Fail <br /> Comments (include information on repairs made prior to testirt and recommendedfollow-u or failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the inf^rmation -Anta;nod i"thic report is true,accurate,and in full compliance with legal requirements. <br /> ``� <br /> Technician's Signature: t, Date:11/27/2007 <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 />