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4111 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/operatorforsubmittal to the local regulatory agency. <br />FACH.ITV INMRMATmN Farility 111• I TcMM <br />Facility Name: Pacific Bell Telephone Co. dba AT&T California Date of Testing: 3/11/2015 <br />Facility Address: 1812 COLEY AVE., Escalon, CA 95320 <br />Facility Contact: Thuy Tran <br />Phone: (209) 474-4022 <br />Date Local Agency Was Notified of Testing. 2015-02-18 <br />Name of Local Agency Inspector (if present during testing): Elena Manzo <br />TEST INC. CnNTRACTnR INFnRMATInN <br />Company Name: TAIT Environmental Services, Inc. <br />Technician Conducting Test: Dan Luck <br />Credential 1 : CSLB Contractor ICC Service Tech. r SWRCB Tank Tester F Other (Specify) <br />License number(s): A B ASB C-10 HAZ License Number 588098 : 5252167 -UT <br />SPII.I, RiiCKF.T TESTING' INFnRMAT1nN <br />Test Method Used: Hydrostatic F Vacuum Other <br />Test Equipment Used: Tape Measure <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 UG01OU001 <br />Bucket Installation Type: <br />f— Direct Bury <br />5_1' Contained in Sump <br />F_ On top of AST <br />F Direct Bury <br />Contained in Sump <br />On top of AST <br />f— Direct Bury <br />f— Contained in Sump <br />On top of AST <br />Direct Bury <br />Contained in Sump <br />On top of AST <br />Bucket Diameter: <br />11" <br />Bucket Depth: <br />14 1/4" <br />Wait time between applying <br />vacuum/water and start of test: <br />15 min <br />Test Start Time (Ti): <br />12:13 PM <br />Initial Reading (Rl): <br />13 3/4" <br />Test End Time (TF): <br />1:13 PM <br />Final Reading (RF): <br />13 3/4" <br />Test Duration (TF —Tt): <br />1 hour <br />Change in Reading (RF -RI): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />Test Result: <br />R Pass f— Fail <br />r Pass r Fail <br />> Pass Fail <br />f— Pass r— Fail <br />Comments —(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />Test water returned 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: 3/11/2015 <br />1, V E L' <br />MEW -is= <br />