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11 <br />Spill Bucket Testing Report Form 21wRCB, January 2006 <br />11 W ,. <br />This form is intended for use by contractors performing annual testing of UST spill co _ leted form and <br />rintouts rom tests i applicable), should beprovided to thefacility owner/o erator or subinitfaVto the"local reg regulatory agency. <br />p f (f PP • ), p .% Y p f g rY S Y• <br />1. FACILITY INFORMATION Facility ID: UG010 <br />Facility Name: Pacific Bell Telephone Co dba ATT California Date of Testing: 02-18-2016 <br />Facility Address: 1812 Coley Ave. Escalon CA 95320 <br />Facility Contact: Thuy Tran I Phone: 209-474-4022 <br />Date Local Agency Was Notified of Testing: 1/15/2016 <br />Name of Local Agency Inspector (ifpresent during testing): Elena Manzo <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TAIT Environmental Services <br />Technician Conducting Test: John Cascio <br />Credentials: ❑x CSLB Contractor O ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specie) <br />License Number(s): A B ASB C-10 HAZ, 588098 5252163 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: OHydrostatic ❑Vacuum []Other <br />Test Equipment Used: Visual Measure <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 UG0100001 <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />❑Direct Bury <br />gContained in Sump <br />[]On Top of AST <br />❑Direct Bury <br />❑Contained in Sump <br />❑On Top of AST <br />❑Direct Bury <br />❑Contained in Sump <br />❑On Top of AST <br />❑Direct Bury <br />❑Contained in Sump <br />0On Top of AST <br />Bucket Diameter: <br />11.00" <br />Bucket Depth: <br />14.25" <br />Wait time between applying <br />vacuum/water and start of test: <br />15 Min <br />Test Start Time (Tj): <br />11:35 AM <br />Initial Reading (Rj): <br />13.75" <br />Test End Time (TF): <br />12:35 PM <br />Final Reading (RF): <br />13.75" <br />Test Duration (TF — Tj): <br />1 Hour <br />Change in Reading (RF - Rj): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />Test Result: <br />_ O Pass []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 />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: 9da &4a* Date: 02-18-2016 <br />j 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 />