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ill 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 Facility ID: UE046 <br /> Facility Name: Pacific Bell Telephone Co. dba AT&T California Date of Testing:3/21/2013 <br /> Facility Address: 907 LINCOLN RD., Stockton,CA 95207 <br /> Facility Contact: Connie Mitchell Phone: (209)474-4022 <br /> Date Local Agency Was Notified of Testing. 2013-03-12 <br /> Name of Local Agency Inspector(ifpresent during testing): Garrett Backus <br /> TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT Environmental Services,Inc. <br /> Technician Conducting Test: Victor Guerrero <br /> Credential t : ! CSLB Contractor F1 ICC Service Tech. r SWRCB Tank Tester r Other(Specify) <br /> License number(s): A B ASB C-10 HAZ License Number 588098 : 8017001-UT <br /> SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic F Vacuum Other <br /> Test Equipment Used: Tape Measure Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 UE046UO02 <br /> Number,Stored Product,etc. <br /> Bucket Installation Type: F Direct Bury F_ Direct Bury r Direct Bury r—Direct Bury <br /> Contained in Sump Contained in Sump F Contained in Sump Contained in Sump <br /> On top of AST On top of AST r On top of AST On top of AST <br /> Bucket Diameter: 11" <br /> Bucket Depth: 15.25" <br /> Wait time between applying 15 min. <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 9:01 am <br /> Initial Reading(Rj): 13.5" <br /> Test End Time(TF): 10:01 am <br /> Final Reading(RF): 13.5" <br /> Test Duration(TF—Tj): 1 hour <br /> Change in Reading(RF-Rj): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Test Result: F Pass Fail F Pass F Fail F Pass r Fail r- Pass r— Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> All test water was taken back to Tait's 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: vwtk- <br /> Date: 3/21/2013 <br />