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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. The completed form and printout from <br />tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />I- FACILITY INFORMATION <br />Facility Name: Pacific Bell Telephone Co. dba AT&T California Date of Testing: 11/22/2010 <br />Facility Address: 44 W. YOKUTS STOCKTON CA 95207.0 GEO PAR # UE656 <br />Facility Contact: Connie Mitchell Facili Phone: 209-4744022 <br />Date Local Agency Was Notified of Testing: 10/20/2010 <br />Name of Local Agency Inspector if present during testing): None <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TAIT ENVIRONMENTAL SERVICES <br />Technician Conducting Test: Victor Guerrero <br />Credentials: ®CSLB Contractor ®ICC Service Tech ❑SWRCB Tank ❑Other (Specify) <br />Tester <br />License Number(s): A ASB HAZB C-10. 588098.8017001 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used ®Hydrostatic ❑Vacuum []Other <br />Identify Spill Bucket (By Tank Number,I 1 UE656A001 12 13 14 <br />Stored Product, etc) <br />Bucket Installation Type <br />❑Direct Bury <br />❑Contained in Sump <br />®On top of AST <br />❑Direct Bury <br />❑Contained in Sump <br />E10n top of AST <br />❑Direct Bury <br />❑Contained in Sump <br />❑ On top of AST <br />❑ Direct Bury <br />❑Contained in Sump <br />❑ On too of AST <br />Bucket Diameter inches <br />15" <br />Bucket Depth inches <br />7" <br />Wait Time between applying <br />vacuum/water and start of test <br />15 Min <br />Test Start Time: <br />11:31 AM <br />Initial Reading <br />53/411 <br />Test End Time: <br />12:31 PM <br />Final Reading <br />5 3/4" <br />Test Duration: <br />1 Hour <br />Change in Reading - Ri : <br />0 <br />Pass/Fail Threshold or Criteria: <br />0 <br />Test Result <br />Pass <br />IComments: All test water was taken back to Tait's shop. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report is true, accurst nd in full compliance with legal requirements <br />Technician's Signature 4,(,, Date 11/22/2010 <br />