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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: UE046 <br /> Facility Name: Pacific Bell Telephone Co dba ATT California I Date of Testing: 2/3/2017 <br /> Facility Address: 907 Lincoln Rd. Stockton CA 95207 <br /> Facility Contact: Thuy Tran t Phone:(209)532-3447 <br /> Date Local Agency Was Notified of Testing : 1/12/2017 <br /> Name of Local Agency Inspector(rfpresent during testing): Vikky McCartney <br /> 2. TESTING CONTRACTOR INFORMATION <br /> ILI <br /> ompany Name: TAIT Environmental Services <br /> echnician Conducting Test: Garrett Warren <br /> redentials': ❑x CSLB Contractor ❑x ICC Service Tech. [I SWRCB Tank Tester E]Other(Spec) <br /> cense Number(s): A B ASB C-10 HAZ, 588098 8185019 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: 0Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Tape Measure Equipment Resolution: 1/16" <br /> L-11 �Ww� <br /> Identify Spill Bucket (By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) UE0460002 <br /> El 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 To of AST <br /> Bucket Diameter: 11.00" <br /> Bucket Depth: 15.00" <br /> Wait time between applying <br /> vacuum/water and start of test: 15 min. <br /> Test Start Time(TI): 1:21 pm <br /> Initial Reading(RI): 13.75" <br /> Test End Time(TF): 2:21 pm <br /> Final Reading(RF): 13.75" <br /> Test Duration(TF—TI): 1 hour <br /> Change in Reading(RF-RI): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Test Result: 0 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 was returned to Tait's shop. <br /> RECEIVED <br /> FEB 15 2017 <br /> ENVIRONMENTAL HEALTH <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TA"1S"I'L�`F S <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: jabe°70"wo Date: 2/3/2017 <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 />