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iil Bucket Testing Report Form <br />This form is intendedfor 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/operatorfbrsubmittal to the local regntlatory agency. <br />FACILITY INFORMATION Facility ID: UG010 <br />Facility Name: Pacific Bell Telephone Co. dba AT&T California Date of Testing:4/11/2013 <br />Facility Address: 1812 COLEY AVE., Escalon, CA 95320 <br />Facility Contact: Gary Chimienti <br />Phone: (925) 468-8103 <br />Date Local Agency Was Notified of Testing: 2013-03-25 <br />Name of Local Agency Inspector (ifpresent during testing): Thuy Tran <br />TESTING CONTRACTOR INFORMATION <br />Company Name: TAIT Environmental Services, Inc. <br />Technician Conducting Test: John Cascio <br />Credential t : CSLB Contractor ICC Service Tech. r SWRCB Tank Tester F Other (Specify) <br />License nrunber(s): A B ASB C-10 HAZ License Number 588098 : 5252163 <br />SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />(,1- Hydrostatic <br />f- Vacuum <br />f- Other <br />Test Equipment Used: Visual Measure <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank I UG01OU001 <br />Number, Stored Produet.etc. <br />Bucket Installation Type: <br />Direct Bury <br />Contained in Sump <br />On top of AST <br />t"- Direct Bury <br />€ Contained in Sump <br />On top of AST <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 />Bucket Diameter: <br />11.00" <br />Bucket Depth: <br />14.50" <br />Wait time between applying <br />vacuum/water and start of test: <br />15 Min. <br />Test Start Time (Tt): <br />9:01 AM <br />Initial Reading (Rt): <br />13.75' <br />Test End Time (TF): <br />10:01 AM <br />Final Reading (RF): <br />13.75' <br />Test Duration (TF - Tt): <br />1 Hour <br />Change in Reading (R£ -Rt): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />Test Result: <br />1✓ Pass Fail <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Comments -(include information on repairs Heade prior to testing, and recommende(Ifollory-up for failed tests) <br />Tesl Wier Returned to Tait <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: 4/11/2013 <br />