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ill Bucket Testing Report Form 0 <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 ID: UE020 <br /> Facility Name: Pacific Bell Telephone Co. dba AT&T California Date of Testing:3/12/2015 <br /> Facility Address: 124 W. ELM ST.,Lodi,CA 95240 <br /> Facility Contact: Thuy Tran Phone: (209)474-4022 <br /> -J <br /> Date Local Agency Was Notified of Testing 2015-02-19 <br /> Name ofLoc aI Agency Inspector(ifpresent during testing): Aris Veloso <br /> 0 V .. ,_ <br /> TESTING CONTRACTOR INFORMATION <br /> PK.+ <br /> Company Name: TAIT Environmental Services,Inc. <br /> Technician Conducting Test: Dan Luck <br /> Credential 1 : r CSLB Contractor rl— ICC Service Tech. r SWRCB Tank Tester Other(Specify) <br /> License number(s): A B ASB C-10 HAZ License Number 588098 : 5252167-UT <br /> SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic f—Vacuum F_ Other <br /> Test Equipment Used: Tape Measure Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 UE02OU001 <br /> Number,Stored Product,etc. <br /> Bucket Installation Type: r' Direct Bury Direct Bury F Direct Bury F_ Direct Bury <br /> Contained in Sump f— Contained in Sump F Contained in Sump r—Contained in Sump <br /> On top of AST On top of AST On top of AST On top of AST <br /> Bucket Diameter: I1" <br /> Bucket Depth: 15 1/2" <br /> Wait time between applying 15 min <br /> vacuum/water and start of test: <br /> Test Start Time(Tt): 12:20pm <br /> Initial Reading(Rt): 15" <br /> Test End Time(TF): 1:20pm <br /> Final Reading(RF): 15" <br /> Test Duration(TF—TI): 1 hour <br /> Change in Reading(RF-RI): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Test Result: r-_1 Pass r Fail Pass r— Fail Pass Fail 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 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: AV 40,04,40e Date: 3/12/2015 <br />