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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 <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Flying J#618 Date of Testing: 0 5 03 2 0 1 7 <br /> Facility Address: 1501 N.Jack Tone Rd. <br /> Facility Contact: Manager Phone 209 599-4141 <br /> Date Local Agency Was Notified of Testing:4.17.17 r=^ <br /> Name of Local Agency Inspector(ifpresent during testing): Aron Hang <br /> 2. TESTING CONTRACTOR INFORMATION � <br /> Company Name:Jones Covey Group,Inc. <br /> Technician Conducting Test: James Blaine <br /> �b6 <br /> Credentials': X CSLB Contractor 9 ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): A,B and Haz 804431 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic D Vacuum ❑Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution: <br /> M , ae ,vm. � ti� <br /> Identify Spill Bucket(By Tank 1T5 91 2 T6 Diesel 3 T7 Waste Water 44 <br /> Number,Stored Product, etc) <br /> Bucket Installation Type: D Direct Bury D Direct Bury ❑Direct Bury ❑Direct Bury <br /> ®Contained in Sump ®Contained in Sump 9 Contained in Sump D Contained in Sump <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 12" 12" 12" <br /> Wait time between applying 15 min 15 min 15 min <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 9:30am 9:30am 1:00pm <br /> Initial Reading(R): 11.75" 11.75" 11.75" <br /> Test End Time(TF): 10:30am 10:30am 2:00pm <br /> Final Reading(RF): 11.75" 11.75" 11.75" <br /> Test Duration(TF—Tj): 1 hour 1 hour 1 hour <br /> Change in Reading(RF-RD: 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Test Result: 19 ]Pass 0 Fail ®<Pass ❑Fail ® Pass ❑Fail ❑ Pass 9 Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> 909 <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: 0503 2 0 1 7 <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 />