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SWRCB,January 2006 <br /> SPILL BUCKET TESTING REPORT FORM <br /> This form is intended/br use by contractors performing annual resting of UST spill containment structures. The completed Orin and printout from <br /> tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name:Pacific Bell Telephone Co.dba AT&T California Date of Testis : 12/04/2009 <br /> FacilLq Address: 124 W.ELM ST.,LODI,CA 95242 GEO PAR#UE020 <br /> Facilky Contact:Connie Mitchell Facility Phone: <br /> Date Local Agency Was Notified of Testing: 12/01/2009 <br /> Name of Local Agency Inspector if present during testing):Thuy Tran <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TAIT ENVIRONMENTAL SERVICES <br /> Technician Conducting Test:John Cascio <br /> Credentials: ®CSLB Contractor ®ICC Service Tech -ISWRCB Tank Other(Specify) <br /> Tester <br /> License Number(s):A ASB ILAZB C-10. 588098:5252163-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used:Visual Measure Equipment Resolution: 1116" <br /> Identify Spill Bucket(By Tank Number, 1 UE020U001 2 3 4 <br /> Stored Product,etc) <br /> ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type MContained in Sump ❑Contained in Sump ❑Contained in Sump ©Contained in Sump <br /> ❑On topof AST ❑On top of AST ❑On top of AST ❑On too of AST <br /> Bucket Diameter inches <br /> Bucket De th inches 15 1/2" <br /> Wait Time between applying 15 min <br /> vacuum/water and start of test <br /> Test Start Time: 11:04 am <br /> Initial Reading Ri): 14 1/4" <br /> Test End Time: 12:04 prn <br /> Final Reading(RD: 14 1/4" <br /> Test Duration: 1 hour <br /> Chan a in Reading Rf-Ri : 0 <br /> Pass/Fail Threshold or Criteria: 0 <br /> Test Result Pass <br /> Comments:All test water was retained in approved containers labeled NON HAZ and transported to Tait. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contaiineed' in this report is true,accurate and in full compliance with legal requirements <br /> Technician's Signature ��'"�,.. �__ Date 12/04/2009 <br />