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SWRCB, January 2006 <br />SPELL BUCKET TESTING REPORT FORM <br />This form is intended for use by contra tompeilbrming annual testing of UST spill containment structures. The completed form and printout from <br />tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />ti hl 1 ca : 1 IJ <br />Facility Name: Pacific Bell Telephone Co. dba AT&T California Date of Testin . 05/18/2030 <br />Facility Address: 124 W. ELM ST., LODI CA 95242 GEO PAR # UE020 <br />Facility Contact: Connie Mitchell Facility Phone: 209-474-4022 <br />Date Local Agency Was Notified of Testing: 04/30/2010 <br />Name of Local A ency Inspector if present during testing): Aris Caca it <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TAIT ENVIRONMENTAL SERVICES <br />Technician Conductin Test: John Cascio <br />Credentials: MCSLB Contractor ®ICC Service Tech ❑ SWRCB Tank Other (Specify) <br />Tester <br />License Num s ; A ASB HAZE C-10 588098:5252163 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used ®Hydrostatic ❑Vacuum []Other <br />Test Equipment Used: Visual Measure Iliquipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank Number, <br />Stored Product, etc) <br />1 UE020U001 <br />2 <br />3 <br />4 <br />Bucket Installation Type <br />Direct Bury <br />®Contained in Sump <br />❑On !T of AST <br />❑Direct Bury <br />❑Contained in Sump <br />❑On to of AST <br />❑ Direct Bury <br />❑Contained in Sump <br />E10n top of AST <br />❑ Direct Bury <br />❑Contained in Sump <br />❑ On top of AST <br />Bucket Diameter inches <br />11" <br />Bucket Depth inches <br />16" <br />Wait Time between applying <br />vacuum/water and start of test <br />15 MIN <br />Test Start Time: <br />9:20 AM <br />Initial Reading Ri): <br />14 1/8" <br />Test End Time: <br />10:20 AM <br />Final Reading <br />14 1/8" <br />Test Duration: <br />1 HOUR <br />Chan a in Reading - Ri : <br />0 <br />Pass/Fail Threshold or Criteria: <br />0 <br />Test Result <br />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 THUS 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 _ �=�' Date 05/18/2010 <br />