Laserfiche WebLink
SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual resting 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 /> I. FACILITY INFORMATION <br /> Facility Name: Sprint Stockton Date of Testis :. 11/7/20I4 <br /> Facility Address: 3807 Coronado Ave <br /> Facility Contact: Doye Phone: 217-663-9440 <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector gfpresent during testing): Fatinah Zareef <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jauregui&Culver inc <br /> Technician Conducting Test: Peter Jauregui III <br /> Credentials`: x CSLB Contractor x ICC Service Tech, ❑SWRCB Tank Tester 0 Other(Specify) <br /> License Number(s): 708231, 8195227 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: x Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Incas Equipment Resolution: +-0.002 <br /> Identify Spill Bucket(By Tank Diesel ` . ..;- <br /> Number, ,Stored Product, etc.) <br /> Z 3 4 <br /> x Direct Bu Bury ❑Direct Bury <br /> Bucket Installation Type: Bury ❑Direct Bury 11 Direct <br /> t-(Contained in Sump ❑Contained in Si-=-R Ll Contained in Sum IJ Contained in Sum <br /> Bucket Diameter; 12" <br /> Bucket Depth: 12'* <br /> Wait time between applying <br /> vacuum/water and start of test: 20 min <br /> Test Start Time(TD: 9:15 <br /> Initial Reading(RI): 1"down from tap <br /> Test End Time(TF): 10:15 <br /> Final Reading(RF): 1"down from top <br /> Test Duration(TF—Tr): I hr <br /> Change in Reading(RF-R�): 0 change <br /> Pass/Fail Threshold or <br /> Criteria: O loss <br /> Test Result: X Pass ❑Fail ❑ Pans ❑Fail ❑ Pass ❑Fail ❑ �[O]Faij <br /> Cont[iteHts—(include information on repairs made prior to testis , andrecommendedfollow-rrPi-failed tests) <br /> Test water was de med non hazardous and removed from site for tune testiniz. <br /> CERTIFICATION OF TECIINICIAIY RESPONSIBLE FOR CONDUCTING TRIS TESTING <br /> I 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: 11-7-14 <br /> ` State laws and regulations do currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />