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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: Pilot 618 Date of Testing: 5 3 2 0 1 8 <br /> Facility Address: 1501 N. Jack Tone <br /> Facility Contact: Manager Phone: 209 599-4141 <br /> Date Local Agency Was Notified of Testing:5/1/2018 <br /> Name of Local Agency Inspector(f present during testing): Betty Ho <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Jones Covey Group,Inc. <br /> Technician Conducting Test: Rogelio Valencia <br /> Credentials': A CSLB Contractor ❑ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): A,B and Haz 804431 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution: <br /> g .+1,,a. <br /> Identify Spill Bucket(By Tank 1 T8 Bio-Diesel 2 3 4 <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: R Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" <br /> Bucket Depth: 12" <br /> Wait time between applying 15-min <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 10:00am <br /> Initial Reading(Rj): 10.5" <br /> Test End Time(TF): 11:00am <br /> Final Reading(RF): 10.5" <br /> Test Duration(TF—Tj): 1 hour <br /> Change in Reading(RF-R,): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Test Result: ®Pass ❑Fail ❑ Pass ®Fail ❑ Pass ®Fail ❑ Pass ®Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> 209 <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: 5 3 2 0 1 8 <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 />