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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 11): UG010 <br />Facility Name: Pacific Bell Telephone Co. dba AT&T California Date of Testing: 6/6/2014 <br />Facility Address: 1812 COLEY AVE., Escalon, CA 95320 <br />Facility Contact: Dave Dube <br />Phone: 209-47411022 <br />Date Local Agency Was Notified of Testing. 2014-05-30 <br />Name of Local Agency Inspector (if present during testing): Elena Manzo <br />11I1l cWHE4a <br />TESTING CONTRACTOR INFORMATION <br />Company Name: TAIT Environmental Services, Inc. ENVIRONMENTAL H <br />Technician Conducting Test: Dan Luck <br />PERMITISERVICEIC <br />Credential T : CSLB Contractor ICC Service Tech. r SWRCB Tank Tester r Other (Specify) <br />License number(s): A B ASB C-10 HAZ License Number 588098 : 5252167 -UT <br />QPIIT RIT(`KFTTFCTIN(_INFORMATInN <br />�r <br />�` <br />Test Method Used: <br />Hydrostatic <br />r Vacuum <br />Other <br />Test Equipment Used: Tape Measure <br />I Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product,etc. <br />1 UG01OU001 <br />Bucket Installation Type: <br />I— Direct Bury <br />rl- Contained in Sump <br />L On top of AST <br />Direct Bury <br />Contained in Sump <br />On top of AST <br />r- Direct Bury <br />r Contained in Sump <br />r 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 1/2" <br />Wait time between applying <br />vacuum/water and start of test: <br />15 min <br />Test Start Time (TI): <br />9:51 am <br />Initial Reading (RI): <br />14" <br />Test End Time (TF): <br />10:51 am <br />Final Reading (RF): <br />14" <br />Test Duration (TF -Tt): <br />I hour <br />Change in Reading (RF -RI): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />Test Result: <br />Pass r- Fail <br />Pass Fail <br />Pass r Fail <br />i Pass Fail <br />Comments -(include information on repairs made prior to testing, and recommended joll ow -up jor failed tests) <br />Test water returned to TAF 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: 6/6/2014 <br />