Laserfiche WebLink
Oill Bucket Testing Report Form <br /> This form is intendedfor use by contractors performing annual testing of UST spill containmen� trtictures. The completed form and <br /> printouts from tests(if applicable),should be provided to the facility owner/operatorforsubmittal 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:3/27/2014 <br /> Facility Address: 124 W. ELM ST.,Lodi,CA 95240 <br /> Facility Contact: Dave Dube Phone: 209-4744022 <br /> Date Local Agency Was Notified of Testing: 2014-03-062 Ell <br /> Name of Local Agency Inspector(ifpresent during testing): Thuy Tran <br /> TESTING CONTRACTOR INFORMATION APR 0 9 2014 <br /> Company Name: TAIT Environmental Services,Inc. <br /> Technician Conducting Test: Victor Guerrero HEALTH DEPARIMN <br /> Credential 1 : P CSLB Contractor r ICC Service Tech. r SWRCB Tank Tester r Other(Specify) <br /> License number(s): A B ASB C-10 HAZ License Number 588098 : 8017001-UT <br /> SPILL BUCKET TESTING INFORMATION <br /> TestMethodUsed: Hydrostatic f-Vacuum r Other <br /> Test Equipment Used: Tape Measure Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank I UE020U001 <br /> Number,Stored Product,etc. <br /> Bucket Installation Type: Direct Bu ryr Direct Bu ryr Direct Bury r Direct Bury <br /> I✓ Contained in Sump Contained in Sump r Contained in Sump r Contained in Sump <br /> r On top of AST On top of AST On top of AST r On top of AST <br /> Bucket Diameter: 11" <br /> Bucket Depth: 16" <br /> Wait time between applying 15 min. <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 11:20 am <br /> Initial Reading(Rj): 14.5" <br /> Test End Time(TF): 12:20 pm <br /> Final Reading(RF): 14.5" <br /> Test Duration(TF—Tj): 1 hour <br /> Change in Reading(RF-Rj): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Test Result: Pass r Fail r' Pass F_ Fail r Pass r Fail r Pass r Fail <br /> Comments—(include information on repairs made prior to testing, and recommendedfollow-up for failed tests) <br /> All test water was taken backto Tait's 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: _e­`% Date: 3/27/2014 <br />