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JUN 04R 916anuary 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment'struciuPe Elie c`orimpletedform 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-Flying J#617 Date of Testing: 0,9/03/2016 <br /> Facility Address: 15100 N. Thornton Lodi CA <br /> Facility Contact: Manager Phone: <br /> Date Local Agency Was Notified of Testing:04/28/2016 <br /> Name of Local Agency Inspector(f present during testing): Aris <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Jones Covey Group,Inc. <br /> Technician Conducting Test: Issac Garcia <br /> Credentials': X 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: Equipment Resolution: <br /> FM <br /> Identify Spill Bucket(By Tank 1 T5 91 2 3 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> 9 Contained in Sum ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12" <br /> Bucket Depth: 12" <br /> Wait time between applying 15 minutes <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 10:00 am <br /> Initial Reading(Rj): 11" <br /> Test End Time(TF): 11:00 am <br /> Final Reading(RF): 11" <br /> Test Duration(Tr—Ti): 1 hour <br /> Change in Reading(RF-Ri): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Test,Result: 'IxI Pass ❑Fail,; © Pass ❑Fail d Pass ❑`fail ,Pass; D 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: 0Z' Date: 05/03/2016 <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 />