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• <br />9. Spill Bucket Testing Report Form <br />Page _of <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: 07/13/07 <br />Facility Address: 110 WEST TURNER ROAD, LODI, CA 95240 <br />Facility Contact: CONNIE MITCHELL Phone: (209) 474-4022 <br />Date Local Agency Was Notified of Testing: 07/10/07 <br />Name of Local Agency Inspector (if present during testing): SAN JOAQUIN ENVIORNMENTAL HEALTH <br />TESTING CONTRACTOR INFORMATION <br />Company Name: TAIT ENVIRONMENTAL SERVICES <br />Technician Conducting Test: MICHAEL STRAWN <br />Credentials': ZCSLB Contractor Z 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: Z Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: VISUAL -MEASURE <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />1 "DIESEL" <br />DIESEL FILL BKT <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />Z Direct Bury <br />❑Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑Contained in Sump <br />❑ Direct Bury <br />❑Contained in Sum <br />Bucket Diameter: <br />12 INCHES <br />Bucket Depth: <br />10 INCHES <br />Wait time between applying <br />vacuum/water and start of test: <br />15 MINUTES <br />Test Start Time (Ti): <br />10:44 AM <br />Initial Reading (Ri): <br />4.4548 <br />Test End Time (TF): <br />10:59 AM <br />Final Reading (RF): <br />4.3685 4.3127 <br />Test Duration (TF — Tj): <br />ONE HOUR <br />Change in Reading (RF - RI): <br />-.0863 -.0444 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />Test Result: <br />❑ Pass Z Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ 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 informatioiu-thi a o�e, accurate, and in full compliance with legal requirements. <br />Technician's Signature: Date: 07/13/07 <br />' State laws and regulations do not currently require performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />