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40 <br /> 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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION Facility ID: UE020 <br /> Facility Name: Pacific Bell Telephone Co dba ATT California I Date of Testing: 2/24/2017 <br /> Facility Address: 124 W. Elm St. Lodi CA 95240 <br /> Facility Contact: Thuy Tran I Phone:(209)53 <br /> Date Local Agency Was Notified of Testing: 2/17/2017 <br /> Name of Local Agency Inspector(ifpresent during testing): Michelle Henry <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT Environmental Services ENVIRONMENTAL HE ff H <br /> Technician Conducting Test: Wes Morrison <br /> Credentials': ❑x CSLB Contractor ❑x ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Sp )" <br /> License Number(s): A B ASB C-10 HAZ, 588098 8250125 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑x Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: tape measure Equipment Resolution: 1/16" <br /> Identify Spill Bucket (By Tank 1 UE0200001 23 4 <br /> Number, Stored Product, etc.) <br /> []Direct Bury []Direct Bury ❑Direct Bury []Direct Bury <br /> Bucket Installation Type: OContained in Sump []Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> ❑On Top of AST ❑On Top of AST ❑On Top of AST ❑On Top of AST <br /> Bucket Diameter: 1V <br /> Bucket Depth: 15.5" <br /> Wait time between applying <br /> vacuum/water and start of test: 15 min <br /> Test Start Time(TI): 1:15pm <br /> Initial Reading(RI): 14.25" <br /> Test End Time(TF): 2:15pm <br /> Final Reading(RF): 14.25" <br /> Test Duration(TF—TI): 1 hr <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 /> Test water returned to Tait shop. <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: "d M&Vz�jm Date: 2/24/2017 <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br /> may be more stringent. <br />