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pill 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/operatorfor submittal to the local regulatory agency. <br />FAC TLITV iNFORMATiON Fnrility ill• ii( nIn <br />Facility Name: Pacific Bell Telephone Co. dba AT&T California Date of Testing: 3/26/2014 <br />Facility Address: 1812 COLEY AVE., Escalon, CA 95320 <br />Facility Contact: Dave Dube <br />Phone: 209-4744022 <br />Date Local Agency Was Notified of Testing. 2014-03-06 <br />Name of Local Agency Inspector (if present during testing): Elena Manzo <br />TESTING CONTRACTOR INFORMATION <br />Company Name: TAIT Environmental Services, Inc. -®' ®"'4-1v I <br />Technician Conducting Test: Victor Guerrero <br />Credential' : r CSLB Contractor F ICC Service Tech. r SWRCB Tank Tester r Other (Specify) <br />License number(s): A B ASB C-10 HAZ License Number 588098 : 8017001 -UT <br />SPILL RiiCKFT TFCTiNG.iNFnRMATinN <br />9, <br />Test M ethod Used: Hydrostatic Vacuum F Other <br />Test Equipment Used: Tape Measure <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 UG010U001 <br />Bucket Installation Type: <br />Direct Bury <br />Contained in Sump <br />On top of AST <br />Direct Bury <br />r Contained in Sump <br />On top of AST' <br />FDirect Bury <br />Contained in Sump <br />On top of AST <br />Direct Bury <br />Contained in Sump <br />r On top of AST <br />Bucket Diameter: <br />11" <br />Bucket Depth: <br />15" <br />Wait time between applying <br />vacuum/water and start of test: <br />15 min. <br />Test Start Time (Ti): <br />NA <br />Initial Reading (Rl): <br />NA <br />Test End Time (TF): <br />NA <br />Final Reading (RF): <br />NA <br />Test Duration (TF — Ti): <br />NA <br />Change in Reading (RF -Ri): <br />NA <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />Test Result: <br />Pass F Fail <br />Pass r— Fail <br />f— Pass r— Fail <br />r— Pass Fail <br />Comments —(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />The spill bucket failed due to leakingdrain valve. All test water was taken backto Tait's shop. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I herebycertify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: Date: 3/26/2014 <br />