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SWRCB, January 2006 <br />Spill Bucket TestingReport 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 (tf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: AT & T Corporation Date of Testing: 5/18/11 <br />Facility Address: 110 W Turner Rd. <br />Facility Contact: Connie Mitchell Phone: (209) 474-4022 <br />L'j <br />ate Local Agency Was Notified of Testing : 4/15/11 <br />ame of Local Agency Inspector (ifpresent during testing): Aris Cacapit <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Service Station Systems <br />Technician Conducting Test: Steve Parmenter <br />Credentials: ® CSLB Contractor © ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): License: 485184 ICC: A28780 -UT (exp: 4/15/13) <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: 0 Hydrostatic ❑ Vacuum 0 e <br />Test Equipment Used: Measuring Tape Equipment Resolution: 1/16 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 UE231UO01 2 3 <br />4 <br />Bucket Installation Type: <br />® Direct Bury ❑ Direct Bury ❑ Direct Bury <br />❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />12 %z in <br />Bucket Depth: <br />14 % in <br />Wait time between applying <br />vacuum/water and start of test: <br />5 min <br />Test Start Time (Tj): <br />10:00 am <br />Initial Reading (RI): <br />14 in <br />Test End Time (TF): <br />11:00 am <br />Final Reading (RF): <br />14 in <br />Test Duration (TF — TI): <br />1.00 hr <br />Change in Reading (RF - RI): <br />0.0000 in <br />Pass/Fail Threshold or <br />Criteria: <br />ZERO LOSS <br />'�est�c�lt� <br />®Pass , ❑ Fail � ❑Pass °❑ Feil C] Past ❑;F�ll. <br />.❑ =Pass C1;Fai1 <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />Test water removed from site. <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 <br />Date: 5/18/11 <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 />