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MAR January 2006 <br /> E <br /> Spill Bucket Testing Report Form fi E.M! ON, IENTAL <br /> This form is intended for use by contractors performing annual testing of UST spill containment'SiFite`twiv�IYWe camp NTdform and <br /> printouts from tests (ii(applicable),should be provided to the facility ownerloperatorfor 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: 03-01-2016 <br /> Facility Address: 124 W. Elm St. Lodi CA 95240 <br /> Facility Contact: Thuy Tran I Phone:209-474-4022 <br /> Date Local Agency Was Notified of Testing: 02-04-2016 <br /> Name of Local Agency Inspector(if present during testing): Aris Veloso <br /> 2. TESTING CONTRACTOR INFORMATION <br /> -Company Name: TAIT Environmental Services <br /> Technician Conducting Test: John Cascio <br /> -Credentialsi: OCSLB Contractor 9 ICC Service Tech. 0 SWRCB Tank Tester [I Other(Specify) <br /> License Number(s): ABASB C-IOHAZ,588098 5252163-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ZHydrostatic []Vacuum []Other <br /> Test Equipment Used: Visual Measure Equipment Resolution: 1/16" <br /> ... <br /> ­ <br /> ..... 11,11— ", 1 ;­ ­ <br /> Identify Spill Bucket(By Tank 1 UE0200001 2 3 4 <br /> Number,Stored Product, etc.) <br /> []Direct Bury E]Direct Bury ElDirect Bury []Direct Bury <br /> Bucket Installation Type: gContained in Sump []Contained in Sump OContained in Sump OContained in Sump <br /> []On To of AST E30n To of AST []On To of AST E10n To of AST <br /> Bucket Diameter: 11.001, <br /> Bucket Depth: 15.50" <br /> Wait time between applying 15 Min <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 12:01 PM <br /> Initial Reading(Rj): 15.00" <br /> Test End Time(TF): 1:01 PM <br /> Final Reading(RF): 15.00" <br /> Test Duration(TF—Tj): <br /> 1 Hour <br /> Change in Reading(RF-Rj): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Test Result: 9 Pass []Fafl ❑ Pass E]Fail [I Pass El 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 <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: 1701M &deza Date: 03-01-2016 <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 />