Laserfiche WebLink
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 Flying J 1017 Date of Testing : 0 8 23 2 0 1 8 <br /> Facility Address : 345 Roth Rd . French Camp Ca , 95231 <br /> Facility Contact : Manager Phone : 865 588-7488 <br /> Date Local Agency Was Notified of Testing : 7-22- 18 <br /> Name of Local Agency Inspector (if present during testing) : Stacy Rivera <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name : Jones Covey Group , Inc. <br /> Technician Conducting Test: Jose Ochoa <br /> Credentials ' : ❑ CSLB Contractor ® 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 ❑ Vacuum ❑ Other <br /> Test Equipment Used : Measuring Tape Equipment Resolution : Visual <br /> Identify Spill Bucket (By Tank 1 87 2 91 3 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type : ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> X Contained in Sump d Contained in Sump ❑ Contained in Sump ❑ Contained in Sum <br /> Bucket Diameter : 12" 12" <br /> Bucket Depth : 16" 16" <br /> Wait time between applying 15 Minutes 15 Minutes <br /> vacuum/water and start of test : <br /> Test Start Time (TI) : 9 : 15 am 9 : 15 am <br /> Initial Reading (RI) : 141 /2 141 /2 <br /> Test End Time (TF) : 10 : 15 am 10 : 15 am <br /> Final Reading (RF) : 141 /2 141 /2 <br /> Test Duration (TF — TI) : 1 Hr. 1 Hr. <br /> Change in Reading (RF - RI) : 0 . 00 0 . 00 <br /> Pass/Fail Threshold or 0 . 00 0 . 00 <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 : (/ Date : 0 8 23 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 /> i <br />