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Page of <br /> 9. 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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> FACILITY INFORMATION <br /> Facility Name: PAC BELL dba AT&T CALIFORNIA Date of Testing: 07/03/07 <br /> Facility Address: 907 LINCOLN ROAD, STOCKTON,CA 95207 <br /> Facility Contact: CONNIE MITCHELL I Phone: (209)474-4022 <br /> Date Local Agency Was Notified of Testing : 06/04/07 <br /> Name of Local Agency Inspector(if present during testing): SAN JOAQUIN ENVIRONMENTAL HEALTH <br /> TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT ENVIRONMENTAL SERVICES <br /> Technician Conducting Test: MICHAEL STRAWN <br /> Credentials': ❑CSLB Contractor Z ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): CSLB=588098 ICC=5262091-UT <br /> SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Z Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used:VISUAL-MEASURE Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 TANK#1171 2 3 4 <br /> Number, Stored Product, etc.) DIESEL FILL BKT. <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑ Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑ Contained in Sump ❑Contained in Sum [-]Contained in Sum <br /> Bucket Diameter: 11 INCHES <br /> Bucket Depth: 10 INCHES <br /> Wait time between applying 15 MINUTES <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:00 A.M. <br /> Initial Reading(Rj): 9.75 INCHES <br /> Test End Time(TF): 10:00 A.M. <br /> Final Reading(RF): 9.75 INCHES <br /> Test Duration(TF—Ti): ONE HOUR <br /> Change in Reading(RF-RI): 0 INCHES <br /> Pass/Fail Threshold or 0 INCHES <br /> Criteria: <br /> Test Resul IL Z Pass ❑ Fail ❑ Pass ❑ Fail I ❑ Pass ❑ Fail I ❑ Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> ALL HYDROSTATIC TEST WATER WAS RECONTAINED IN 1 FIVE GALLON POLY DRUM. <br /> DRUM IS LABELED AS NON-HAZ AND WAS REMOVED BY TAIT. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the informatio tail .t this report is true,accurate, and in full compliance with legal requirements. <br /> Technician's Signature: — Date: 07/03/07 <br /> _J <br /> ' State laws and regulations do not currently req ' stin be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />