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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 <br /> printouts from tests(:f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: New Cingular Wireless PCS,LLC dba AT&T Mobility Date of Testing: 1-13-11 <br /> Facility Address: 6855 W.Eight Mile Rd.,Stockton,CA 95219 GeoPar#:USID92230 <br /> Facility Contact: Jody Rhoades Phone: (925)288-9898 <br /> Date Local Agency Was Notified of Testing: 1-10-11 <br /> Name of Local Agency Inspector(if present during testing): N/A <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: CALIFORNIA HAZARDOUS,INC. <br /> Technician Conducting Test: Raul Ochoa <br /> Credentials': ®CSLB Contractor ®ICC Service Tech. ❑ SWRC13 Tank Tester ❑Other(Specify) <br /> License Number(s):734854 ICC#: 8029272-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑Hydrostatic ❑Vacuum ® Other <br /> Test Equipment Used:Tape Measure Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank USID 92230 A001 <br /> Number, Stored Product, etc. <br /> ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑Contained in Sump ❑Contained in Sump El Contained in Sump El Contained in Sump <br /> ®On Top of AST ❑On Top of AST ❑On Top of AST ❑On Top of AST <br /> Bucket Diameter: 15in <br /> Bucket Depth: 15in <br /> Wait time between applying 15minutes <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 11:30am <br /> Initial Reading(RI): flinches <br /> Test End Time(TF): 12:30pm <br /> Final Reading(RF): 8inches <br /> Test Duration(TF—TI): 1 Hour <br /> Change in Reading(RF-RI): none <br /> Pass/Fail Threshold or Criteria: No detectable loss <br /> Test Result: ® Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <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/ this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: V�k Date 1-13-11 <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be <br /> more strineent. <br />