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L] <br />E <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 printout.fiom <br />tests (if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agencv. <br />1. FACILITY INFORMATION <br />Facility Name: AT&T Corporation Date of Testing: 06/17/2009 <br />Facility Address: J110 W. Turner Rd. Lodi CA 95242 GEO PAR # UE231 <br />Facility Contact: Connie Mitchell Facilit • Phone: <br />Date Local Agency Was Notified of "restin : 05/28/2009 <br />Name of Local Agency Inspector if present during testing): Aris Caca it <br />2. TESTING CONTRACTOR INFORMATION <br />Company_Name: TAIT ENVIRONMENTAL SERVICES <br />Technician Conducting Test, Christopher Derosier <br />Credentials: ®CSLB Contractor ®ICC Service Tech ❑SWRCB Tank ❑Other (Specify) <br />Tester <br />License Number(s): A ASB HAZB C-10. 588098; B35665 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used ®Hydrostatic ❑ Vacuum ❑Other <br />Test E ui ment Used: Incon E ui ment Resolution: .0006 <br />ldentiAi Spill Bucket (BY Tank -Number, <br />Storer! Product, etc) <br />1 UE2310001 <br />2 <br />3 <br />4 <br />Bucket Installation Type <br />®Direct Bury <br />❑Contained in Sump <br />❑Direct Bury <br />❑Contained in Sump <br />❑Direct Bury <br />❑Contained in Sump <br />❑ Direct Bury <br />❑Contained in Sump <br />Bucket Diameter inches <br />12" <br />Bucket Depth inches <br />15" <br />Wait Time between applying <br />vacuum/water and start of test <br />15 min <br />Test Start Time: <br />9:31am / 9:46am <br />Initial Reading Ri): <br />3.8595 / 3.8574 <br />Test End Time: <br />9:46am / 10:01am <br />Final Reading (R#): <br />3.8576 / 3.8569 <br />Test Duration: <br />15min / 15min <br />Chan a in Readin (Rf - Ri): <br />.0019/.0005 <br />Pass/Fail Threshold or Criteria: <br />Passed <br />Test Result <br />Pass <br />— <br />Comments: Removed water from spill bucket after test water was placed in 5 gallon bucket. Marked water non haz and returned to <br />Tait's shop. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that ail the information contained in this report is true, accurate and in full compliance with legal requirements <br />Date 06117/2009 <br />Technician's Signature V 4 <br />