Laserfiche WebLink
a <br /> O <br /> pill 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 /> printoutsfrom tests(if applicable),should be provided to the facility owner/operatorforsubmittal to the local regulatory agency. <br /> FACILITY INFORMATION Facility ID: UE042 <br /> Facility Name: Pacific Bell Telephone Co. dba AT&T California Date of Testing:4/19/2012 <br /> Facility Address: 345 N.SAN JOAQUIN,Stockton,CA 95202 <br /> Facility Contact: Connie Mitchell Phone: 209-47411022 <br /> Date Local Agency Was Notified of Testing: 3/15/2012 <br /> Name of Local Agency Inspector(if present during testing): Jeff Wong <br /> TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT Environmental Services,Inc. <br /> Technician Conducting Test: Tim Minard <br /> Credential t : F 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 : 5292650-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 UE042UO01 <br /> Number,Stored Product,etc.) <br /> Bucket Installation Type: F Direct Bury F Direct Bury F Direct Bury F Direct Bury <br /> F Contained in Sump F Contained in Sump F Contained in Sump F Contained in Sump <br /> F On top of AST F On top of AST On top of AST On top of AST <br /> Bucket Diameter: 12" <br /> Bucket Depth: 14" <br /> Wait time between applying 30 min <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 10:01am <br /> Initial Reading(Rt): 14" <br /> Test End Time(TF): 11:01 am <br /> Final Reading(RF): 14" <br /> Test Duration(TF—Tj): 1Hr <br /> Change in Reading(RF-RI): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Test Result: F Pass F Fail F Pass FFailF Pass f— Fail F Pass r Fail <br /> Comments—(include information on repairs made prior to testing, and recom mendedfollow-up for failed tests) <br /> Test water was reWmed 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: Date: 4/19/2012 <br />