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Ohl 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 Facility ID: UE020 <br /> Facility Name: Pacific Bell Telephone Co. dba AT&T California Date of Testing:4/19/2012 <br /> Facility Address: 124 W. ELM ST.,Lodi,CA 95240 <br /> Facility Contact: Connie Mitchel Phone: 209-598-5155 <br /> Date Local Agency Was Notified of Testing: 3/15/2012 <br /> Name of Local Agency Inspector(ifpresentduring testing): Aris Cacapit <br /> TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT Environmental Services,Inc. <br /> Technician Conducting Test: Tim Minard <br /> Credential t : CSLB ContractorICC Service Tech. r SWRCB Tank Tester Other(Specify) <br /> License number(s): A B ASB C-10 HAZ License Number 588098 : 5292650-UT <br /> SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic Vacuum F Other <br /> Test Equipment Used: Tape Measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 UE020U001 <br /> Number,Stored Product,etc.) <br /> Bucket Installation Type: r— Direct Bury F Direct Bury "Direct Bury F Direct Bury <br /> W Contained in Sump F Contained in Sump Contained in Sump Contained in Sump <br /> r— On top of AST On top of AST On top of AST On top of AST <br /> Bucket Diameter: 12" <br /> Bucket Depth: 15" <br /> Wait time between applying 30 min <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 2:07pm <br /> Initial Reading(Rl): 13.25" <br /> Test End Time(TF): 3:07pm <br /> Final Reading(RF): 13.25" <br /> Test Duration(TF—TI): 1 Hr <br /> Change in Reading(RF-Rt): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Test Result: r' Pass F' Fail Pass r- Fail Pass Fail r— Pass r Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> All test water was taken back to Tait's shop. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I he reby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: � Date: 4/19/2012 <br />