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%ill Bucket Testing Report ort 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: UE058 <br /> Facility Name: Pacific Bell Telephone Co. dba AT&T California Date of Testing:4/25/2012 <br /> Facility Address: 10 E. 12TH ST.,Tracy,CA 95376 <br /> Facility Contact: Connie Mitchell Phone: 209-474-3022 <br /> Date Local Agency Was Notified of Testing: 4/5/2012 <br /> Name of Local Agency Inspector(ifpresent during testing): Garrett Backus <br /> TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT Environmental Services,Inca <br /> Technician Conducting Test: John Cascio <br /> Credential 1 : P_ CSLB Contractor P ICC Service Tech. r- SWRCB Tank Tester 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: F Hydrostatic F Vacuum r- Other <br /> Test Equipment Used: Visual Measure Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 UE058U002 <br /> Number,Stored Product,etc.) <br /> Bucket Installation Type: r Direct Bury r Direct Bury r Direct Bury I- Direct Bury <br /> F Contained in Sump f- Contained in Sump r-Contained in Sump F Contained in Sump <br /> r On top of AST On top of AST On top of AST On top of AST <br /> Bucket Diameter: 11.00" <br /> Bucket Depth: 14.25" <br /> Wait time between applying 15 Min. <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 11:15 AM <br /> Initial Reading(RI): 13.50" <br /> Test End Time(TF): 12:15 PM <br /> Final Reading(RF): 13.50" <br /> Test Duration(TF-Tt): 1 Hour <br /> Change in Reading(RF-RI): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Test Result: Pass Fail �' Pass Fail Pass r- Fail r- Pass r Fail <br /> Comments-(include information on repairs made prior to testing, and recommendedfollow-up for failed tests) <br /> Test Wler Returied To Tait <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: 4/25/2012 <br />