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*H1 Bucket Testing Report For <br /> This form is intendedfor 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.fercility owner/operator.forsubmittal 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:4/5/2013 <br /> Facility Address: 124 W. ELM ST.,Lodi,CA 95240 <br /> Facility Contact: Gary Chimienti Phone: (925)468-8103 <br /> Date Local Agency Was Notified of Testing: 2013-03-25 <br /> Name of Local Agency Inspector(if present during testing). Aris Cacapit <br /> TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT Environmental Services,Inc. <br /> Techni cian Conducting Test: John Cascio <br /> Credential t : R 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 : 5252163 <br /> SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic Vacuum Other <br /> Test Equipment Used: Visual Measure Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 UE020U001 <br /> Number,Stored Product,etc. <br /> Bucket Installation Type: k_'' Direct Bury f- Direct Bury €F-Direct Bury -Direct Bury <br /> P- Contained in Sump FContained in Sump F-Contained in Sump r- Contained in Sump <br /> On top of AST On top of AST On top of AST F On top of AST <br /> Bucket Diameter: 11.00" <br /> Bucket Depth: 16.25" <br /> Wait time between applying 15 Min. <br /> vacuum/water and start of test: <br /> Test Start Time(T1): 1:01 PM <br /> Initial Reading(Rt): 15.00" <br /> Test End Time(TF): 2:01 PM <br /> Final Reading(RF): 15.00" <br /> Test Duration(TF-Tt): 1 Hour <br /> Change in Reading(RF-R1): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Test Result: Pass Fail r- Pass F- Fail r- Pass r- Fail Pass r- Fail <br /> Comments-(include information on repairs made prior to testing, and recommendedfollow-up for failed tests) <br /> Test Water Retumed to Tait <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTINGTHIS TESTING <br /> 1 hereby certify that all the information contained in this report is trite, accurate, and in full compliance with legal requirements. <br /> Technician's Signature: Date: 4/5/2013 <br />