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f . <br /> 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#618 Date of Testing: 5 14 2 0 1 4 <br /> Facility Address: 1501 N.Jack Tone Road <br /> Facility Contact: Holly Marlowe Phone: 209 599-4141 <br /> Date Local Agency Was Notified of Testing: 4/21/14 <br /> Name of Local Agency Inspector(ifpresent during testing): Ins ector Jeff Won <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Jones Covey Group,Inc. <br /> Technician Conducting Test: Edwin Coreas. <br /> Credentials: Xi;CSLB Contractor IT ICC Service Tech. ®SWRCB Tank Tester 7 Other(Spec) <br /> License Number(s): A,B and Haz 804431 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: LA Hydrostatic ❑Vacuum 0 Other <br /> Test Equipment Used: Visual Equipment Resolution: Visual <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number,Stored Product, etc.) DSL-fill DSL-fill Dsl-Fill Auto Diesel <br /> Bucket Installation Type: IV Direct Bury X Direct Bury 9 Direct Bury M Direct Bury <br /> Contained in Sump 10 Contained in Sump 0 Contained in Sum ❑Contained in Sum <br /> Bucket Diameter: 12" 15" 15" 12" <br /> Bucket Depth: 12" 12" 12" 12" <br /> Wait time between applying <br /> vacuum/water and start of test: 15 min. 15 min. 15 min. 15 <br /> Test Start Time(T,): 9:00am 9:00am 9:00am 9:00am <br /> Initial Reading(Rj): 11" 11.5" 11.5" 11" <br /> Test End Time(TF): 10:00am 10:00am 10:00am 10:00am <br /> Final Reading(RF): 11" 11.5" 11.5" 11" <br /> Test Duration(TF—T,): 1 Hour 1 Hour 1 Hour 1 Hour <br /> Change in Reading(RF-Rj): 0" 0" 0" 0" <br /> Pass/Fail Threshold or No Visual leaks No Visual leaks No Visual leaks No Visual leaks <br /> Criteria: <br /> Test Result: N Pass ❑Fail 9 Pass D Fail 91 Pass ❑Fail ® Pass 0 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 /> "�' <br /> Technician's Signature: Date: 5 14 2014 <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 />