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1 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 Facilitv ID: UG010 <br />Facility Name: Pacific Bell Telephone Co. dba AT&T California Date of Testing: 4/25/2012 <br />Facility Address: 1812 COLEY AVE., Escalon, CA 95320 <br />Facility Contact: Connie Mitchell <br />Phone: 209-47411022 <br />Date Local Agency Was Notified of Testing. 4/5/2012 <br />Name of Local Agency Inspector (if present during testing): Garrett Backus <br />TFCTiNr CnNTRACTnR INFORMATInN <br />Company Name: TAIT Environmental Services, Inc. <br />Technician Conducting Test: John Cascio <br />Credential 1 : CSLB Contractor P ICC Service Tech. SWRCB Tank Tester r Other (Specify) <br />License number(s): A B ASB C-10 HAZ License Number 588098 : 5252163 <br />CPii.I. RIT KF.T TRRTINC_ INMRMATmN <br />Test Method Used: W' Hydrostatic f— Vacuum r— Other <br />Test Equipment Used: Visual <br />Measure Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product,etc. <br />1 UG010U001 <br />Bucket Installation Type: <br />I— Direct Bury <br />Contained in Sump <br />On top of AST <br />Direct Bury <br />r Contained in Sump <br />On top of AST <br />f— Direct Bury Direct Bury <br />r— Contained in Sump Contained in Sump <br />On top of AST On top of AST <br />Bucket Diameter: <br />11.00" <br />Bucket Depth: <br />14.50" <br />Wait time between applying <br />vacuum/water and start of test: <br />15 Min. <br />Test Start Time (Tt): <br />9:01 AM <br />Initial Reading (RI): <br />14.00" <br />Test End Time (TF): <br />10:01 AM <br />Final Reading (RF): <br />14.00" <br />Test Duration (TF — TI): <br />1 Hour <br />Change in Reading (RF -RI): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />Test Result: <br />P7 Pass f— Fail <br />f— Pass Fail <br />Pass r Fail r Pass Fail <br />Comments —(include information on repairs made prior to testing, and recommendedfollow-up for failed tests) <br />Test Water RetumedTo 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:Date: 4/25/2012 <br />