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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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1_ FAC.11,ITV INFORM ATInN <br />Facility Name: Pilot Flying J 618 Date of Testing: 5 22 2 0 13 <br />Facility Address: 1501 N. Jackton Rd. <br />Facility Contact: Holly Marlowe Phone: 209-599-4141 <br />Date Local Agency Was Notified of Testing: 5/3/2013 <br />Name of Local Agency Inspector (f present during testing): Garrett Backus <br />2_ TF.CTINC, CnNTRACTnR INFnRMATinN <br />Company Name: Jones Covey Group, Inc. <br />Technician Conducting Test: Edwin Coreas <br />Credentials': EKI 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: <br />❑ Hydrostatic <br />❑ Vacuum <br />FK] Other <br />Test Equipment Used: Tape <br />Equipment Resolution: Visual <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />191 FB -VB <br />2 Auto Diesel <br />3 <br />4 <br />Bucket Installation Type: <br />Fc Direct Bury <br />❑ Contained in Sump <br />W Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />12" <br />12" <br />12" <br />Bucket Depth: <br />12" <br />12" <br />12" <br />Wait time between applying <br />vacuum/water and start of test: <br />15Min <br />15Min <br />15Min <br />Test Start Time (Ti): <br />9:00 <br />9:00 <br />9:00 <br />Initial Reading (Ri): <br />11" <br />11" <br />11" <br />Test End Time (TF): <br />10:00 <br />10:00 <br />10:00 <br />Final Reading (RF): <br />11" <br />11" <br />11" <br />Test Duration (TF — TI): <br />1 Hr <br />1 Hr <br />1 Hr <br />Change in Reading (RF - RT): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />0 <br />Test Result: <br />® Pass 0 Fail <br />0 Pass ❑ Fail 'l <br />0 Pass d Fail <br />0 Pass'❑Fail <br />Uomments — (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 <br />Date: 5 22 2 0 13 <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 />