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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: Pilot Flying J#618 1 Date of Testing: 5 14 2 0 1 4 <br /> Facility Address: 1501 Jack tone Road Ripon CA, 95366 <br /> Facility Contact: Manger I Phone: 209 599-4141 <br /> Date Local Agency Was Notified of Testing: 4/21/2014 <br /> Name of Local Agency Inspector(if present during testing): tns ector Jeff Won <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Jones Covey Group,Inc. <br /> Technician Conducting Test: Edwin Coreas. <br /> Credentials: L CSLB Contractor ®ICC Service Tech. 9 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: Visual Equipment Resolution: Visual <br /> .. <br /> Identify Spill Bucket(By Tank 1 Z 3 4 <br /> Number,Stored Product, etc.) 91-fill 87-fill Oil&Water Sep. Bio Diesel <br /> Direct Bury ®Direct Bury 0 Direct Bury !0 Direct Bury <br /> Bucket Installation Type: F-1 Contained in Sum ❑Contained in Sump N1 Contained in Sump X Contained in Sum <br /> Bucket Diameter: 12" 15" 12" 12" <br /> Bucket Depth: 13" 12" 12" 12" <br /> Wait time between applying <br /> v 15 min. 15 min. 15 min. 15 min. <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 9:00am 9:00am 4:00pm 2:00pm <br /> Initial Reading(Rj): ill, ill, 11.5" ill, <br /> Test End Time(TF): 10:00am 10:00am 5:00pm 3:00pm <br /> Final Reading(RF): ill, ill, 11.5" ill, <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: _ ® Pass ,❑Fait ® Pass ❑Fait ® Pass ❑Fail: 19 Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> 209 <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: 5 14 2 0 1 4 <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 />