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t Y t <br />1 Bucket Testing Report Fo <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts <br />from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION CLLC: LODICA01 GEO PAR: UE -020 <br />Facility Name: AT&T/SBC Date of Testing: 7/19/06 <br />Facility Address: 124 W. ELM STREET, LODI <br />Facility Contact: TOM WILLIAMS I Phone: 209-466-1010 <br />Date Local Agency Was Notified of Testing: 48 HOURS PRIOR (MIN) <br />Name of Local Agency Inspector (if present during testing): SAN JOAQUIN ENVIRONMENTAL HEALTH <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TAIT ENVIRONMENTAL SYSTEMS <br />Technician Conducting Test: MICHAEL L. STRAWN, II <br />Credentials: ® CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): A B ASB C-10 HAZ License Number: 588098 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: VISUAL / MEASURE <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank 1 TANK #1214 <br />Number, Stored Product, DIESEL FILL <br />etc.) BUCKET <br />Bucket Installation Type: ❑ Direct Bury <br />® Contained in Sure <br />2 <br />❑ Direct Bury <br />❑ Contained in Sump <br />3 <br />❑ Direct Bury <br />❑ Contained in Sump <br />4 <br />❑ Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: 11" <br />Bucket Depth: 10" <br />Wait time between applying 15 MINUTES <br />vacuum/water and start of test: <br />Test Start Time (Ti): 3:15 P.M. <br />Initial Reading (RI): 9.75" <br />Test End Time (TF): 4:15 P.M. <br />Final Reading (RF): 9.75" <br />Test Duration (TF — TI): %2 HOUR <br />Change in Reading (RF - R,): 3" <br />Pass/Fail Threshold or ,002" <br />Criteria: <br />rest Result: ® Pass ❑Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Cron <br />invents — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />*All hazardous test water was re -contained in (1) S gallon steel drum. Drum is labeled non-haz and is <br />Ready for pick-up. <br />*Spill Bucket passed test. No repairs are needed at present time. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />f <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: 7/19/06 <br />