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SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing pertodic testing of UST secondary containment systems Use the <br /> appropriate pages of this form to report results for all components tested The completed form,written test procedures,mrd <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 Stockton — I Date of Testing: 11107/2014 <br /> Facility Address: 3807 Coronado Ave. Stockton 35204 <br /> Facility Contact: Doye Phone: 217-663-3440 <br /> Date Local Agency Was Notified of Testing: <br /> Nme of Local Agency Inspector(ipresent during testing): Fatinah Zareef <br /> 2. TES'T'ING CONTRACTOR INFORMATION <br /> Company Name: lauregui&Culver inc <br /> Technician Conducting Test: Peter 7auregui III <br /> Credentials: X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,B,C21,Haz License Number:708231 <br /> Manufacturer Training <br /> Manufacturer Component(s) _ Date Training Expires <br /> Incon 7602133701 5-13-2015 <br /> ICC 8195227 6-13-2015 <br /> 3. SUMMARY(1F TEST RESULTS <br /> Component Pass Fail Not Repairs Nat Repairs <br /> P Tested Made Component Pass Fail Tested Made <br /> Diesel sump UST X ❑ ❑ ❑ Diesel sump AST X ❑ ❑ ❑ <br /> Spill bucket X ❑ ❑ ❑ Piping secondary UST X ❑ ❑ ❑ <br /> Diesel Annular UST ❑ ❑ X ❑ Piping secondary AST X ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 17 ❑ 11 ❑ ❑ ❑ El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ 1 -OF ❑ ❑ <br /> D LJ ❑ ❑ ❑ I ❑ I ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> Test Water was deemed non-hazardous and removed at the time of test to be used <br /> On Future tests. <br /> CERTIFICATION OF TECHMCIAN RESPONSIBLE FOR CONDUCTING TWS TESMG <br /> To the best of my knowledge,th stated in this document are accurate and in full compliance with legal requirements <br /> M <br /> Technician's Signature: Date: 11/7/2014 <br />