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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 printout from <br /> tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: Pacific Bell Telephone Co.dba AT&T California Date of Testing: 06/03/2009 <br /> Facility Address: 10 E. 12TH ST. TRACY CA 95376 GEO PAR#UE058 <br /> Facility Contact:Connie Mitchell Facility Phone: <br /> Date Local Agency Was Notified of Testing: 05/01/2009 <br /> Name of Local Agency Inspector if present during testing): Michelle Henry <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT ENVIRONMENTAL SERVICES <br /> Technician Conducting Test: John Cascio <br /> Credentials: ®CSLB Contractor ®ICC Service Tech ❑SWRCB Tank []Other(Specify) <br /> Tester <br /> License Number(s):A ASB HAZB C-10. 588098 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Visual Measure I Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank Number, 1 UE058U002 2 3 4 <br /> Stored Product,etc) <br /> Bucket Installation Type ❑Direct Bury El Direct Bury ❑Direct Bury ❑Direct Bury <br /> ®Contained in Sump [:]Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter inches lift <br /> Bucket Depth inches 14 1/4" <br /> Wait Time between applying 15min <br /> vacuum/water and start of test <br /> Test Start Time: 1:01 m <br /> Initial Reading Ri): 14 1/4" <br /> Test End Time: 2:01 m <br /> Final Reading(Rf): 14 1/4" <br /> Test Duration: 1 hour <br /> Chane in Reading Rf-Ri : 0 <br /> Pass/Fail Threshold or Criteria: 0 <br /> Test Result Pass <br /> Comments:All test water was retained in approved containers labeled non haz and transported to Tait's 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 06/03/2009 <br />