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E <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 printout from <br />tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Pacific Bell Telephone Co. dba AT&T California Date of Testing: 05/21/2009 <br />Facility Address: 907 LINCOLN RD. STOCKTON CA 95207 GEO PAR # UE046 <br />Facility Contact: Connie Mitchell Facility Phone: <br />Date Local Agency Was Notified of Testing: 04/24/2009 <br />Name of Local Agency Inspector if present during testing): Garrett Backus <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TAIT ENVIRONMENTAL SERVICES <br />Technician Conducting Test: Christopher Derosier <br />Credentials: ®CSLB Contractor ®ICC Service Tech ❑SWRCB Tank ❑Other (Specify) <br />Tester <br />License Number(s): A ASB HAZB C-10. 588098 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used ®Hydrostatic ❑ Vacuum ❑Other <br />Test Eauipment Used: Visual/Measured and Marked I Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank Number, 1 UE046UO02 2 3 4 <br />Stored Product, etc) <br />Bucket Installation Type <br />❑Direct Bury <br />®Contained in Sump <br />El Direct Bury <br />El Contained in Sump <br />❑ Direct Bury <br />❑Contained in Sump <br />❑ Direct Bury <br />❑Contained in Sump <br />Bucket Diameter inches <br />12" <br />Bucket Depth inches <br />14" <br />Wait Time between applying <br />vacuum/water and start of test <br />15min <br />Test Start Time: <br />10:15am <br />Initial Reading Ri): <br />14" <br />Test End Time: <br />10:16 <br />Final Reading (Rf): <br />11 3/4" <br />Test Duration: <br />1 min <br />Change in Reading Rf - Ri : <br />2 1/4" <br />Pass/Fail Threshold or Criteria: <br />0 <br />Test Result <br />Fail <br />Comments: Removed water from spill bucket, marked it non haz and returned it 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 Date 05/21/2009 <br />