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SEP 0 9 2016 <br /> SWRCB,January 2006 <br /> Spill 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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION Facility ID: UE042 <br /> Facility Name: Pacific Bell Telephone Co dba ATT California Date of Testing: 8/17/2016 <br /> Facility Address: 345 N.San Joaquin Stockton CA 95202 <br /> Facility Contact: Thuy Tran Phone:(209)532-3447 <br /> Date Local Agency Was Notified of Testing: 7/15/2016 <br /> Name of Local Agency Inspector(f present during testing): Stacy Rivera <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT Environmental Services <br /> Technician Conducting Test: Pat Banbury <br /> Credentials': ❑x CSLB Contractor 0 ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): A B ASB C-10 HAZ,588098 ICC: 5254955 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: OHydrostatic []Vacuum ❑Other <br /> Test Equipment Used: Tape Measure Equipment Resolution: 1/1 6th inch <br /> Identify Spill Bucket(By Tank I UE0420001 2 3 4 <br /> Number, Stored Product, etc.) <br /> ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑x Contained in Sump ❑Contained in Sump []Contained in Sump ❑Contained in Sump <br /> El On Top of AST [I On Top of AST ❑On Top of AST ❑On Top of AST <br /> Bucket Diameter: 11" <br /> Bucket Depth: 14.5" <br /> Wait time between applying 15 Min <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:15 AM <br /> Initial Reading(Rj): 13.50" <br /> Test End Time(TF): 10:15 AM <br /> Final Reading(RF): 13.50" <br /> Test Duration(TF—Tz): One Hour <br /> Change in Reading(RF-RI): 0.00" <br /> Pass/Fail Threshold or <br /> Criteria: 0.00" <br /> Test Result: ❑x Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> Transport test water 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: Pa Date: 8/17/2016 <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />