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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: Ripon 618 Date of Testing: 5 3 2 0 1 8 <br /> Facility Address: 1501 N. Jack Tone <br /> Facility Contact: Manager Phone: 209 559-4141 <br /> Date Local Agency Was Notified of Testing:5/1/18 <br /> Name of Local Agency Inspector(if 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': ❑CSLB Contractor X 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: X Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc. T5 91 T6 Auto Diesel T7 waste water <br /> Bucket Installation Type: k Direct Bury k Direct Bury X Direct Bury ❑i Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum2 ❑Contained in Sum <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(Tj): 10:00am 10:00am 6:30pm <br /> Initial Reading(Rj): 10" 10" 10.5" <br /> Test End Time(TF): 11:00am 11:00am 7:30pm <br /> Final Reading(RF): 10" 10" 10.5" <br /> Test Duration(TF—TI): 1 hour 1 hour 1 hour <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or 0 0 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 /> 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: j / i'' Date: 5 3 2 0 1 8 <br /> ' State laws and regulations do not currently require testing to oe performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />