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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(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name:Pacific Bell Telephone Co. dba AT&T California Date of Testing:06/02/2009 <br /> Facility Address: 124 W. ELM ST. LODI CA 95242 GEO PAR#UE020 <br /> Facility Contact: Connie Mitchell Facility Phone: <br /> Date Local Agency Was Notified of Testing: 05/01/2009 <br /> Name of Local Agency Inspector if present during testing):Aris Caca it <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT ENVIRONMENTAL SERVICES <br /> Technician Conducting Test:John Cascio <br /> Credentials: ®CSLB Contractor ®ICC Service Tech ❑SWRCB Tank ❑Other(Specify) <br /> Tester <br /> License Number (s):A ASB HAZB C-10; 588098 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Visual Measure I Equipment Resolution: 1/16" <br /> Idents Spill Bucket(By Tank Number, 1 UE020U001 2 3 4 <br /> Stored Product,etc) <br /> Bucket Installation Type ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> ®Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter inches 11" <br /> Bucket Depth inches 14" <br /> Wait Time between applying 15 min <br /> vacuum/water and start of test <br /> Test Start Time: 9:01 am <br /> Initial Reading Ri): 13 1/4" <br /> Test End Time: 10:01am <br /> Final Reading(Rf): 13 1/4" <br /> Test Duration: 1 hour <br /> Change in Reading Rf-Rz : 0 <br /> Pass/Fail Threshold or Criteria: 0 <br /> Test Result Pass <br /> Comments:All test water was retained in approved containers labeled non haz and transported to Tait. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS 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 06/02/2009 <br />