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Page of <br /> 9. 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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> FACILITY INFORMATION <br /> Facility Name: PAC BELL dba AT&T CALIFORNIA I Date of Testing: 07/05/07 <br /> Facility Address: 124 W.ELM ST. LODI,CA 95240 <br /> Facility Contact: CONNIE MITCHELL Phone: (209)466-1010 <br /> Date Local Agency Was Notified of Testing: 06/04/07 <br /> Name of Local Agency Inspector(if present during testing): SAN JOAQUIN ENVIRONMENTAL HEALTH <br /> TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT ENVIRONMENTAL SERVICES <br /> Technician Conducting Test: MICHAEL STRAWN <br /> Credentials: ®CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): CSLB=588098 ICC=5262091 -UT <br /> SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used:VISUAL/MEASURE Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 TANK#1214 2 3 4 <br /> Number, Stored Product, etc.2 DIESEL FILL BKT. <br /> Bucket Installation Type: ®Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑ Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 11 INCHES <br /> Bucket Depth: 10 INCHES <br /> Wait time between applying 15 MINUTES <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:00 AM <br /> Initial Reading(Ri): 9.75 INCHES <br /> Test End Time(TF): 10:00 AM <br /> Final Reading(RF): 9.75 INCHES <br /> Test Duration(TF—Tj): ONE HOUR <br /> Change in Reading(RF-RI): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <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 /> ALL HYDROSTATIC TEST WATER WAS RECONTAINED IN(1)FIVE GALLON POLY DRUM. <br /> DRUM IS LABELED AS NON-HAZ AND WAS REMOVED BY 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: 07/05/07 <br /> State laws and regulations do not currently requirees ' g o be performed by a qualified contractor. However,local requirements <br /> may be more stringent. <br />