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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. FACILITY INFORMATION <br /> Facility Name: Pilot-Flying J#618 Date of Testing: 0 5 14 2 0 1 5 <br /> Facility Address: 1501 N Jack Tone Rd. <br /> Facility Contact: Manager Phone: <br /> Date Local Agency Was Notified of Testing:4/16/15 <br /> Name of Local Agency Inspector(f present during testing): Elena Manzo <br /> JUN 1. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Jones Covey Group,Inc. " N <br /> Technician Conducting Test: Issas Garcia u <br /> ., ., . <br /> Credentials: X 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: 9 Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc. T1 Diesel T2 Diesel T3 Diesel T4 87 <br /> Bucket Installation Type: Direct Bury X Direct Bury x Direct Bury iK Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump 0 Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 15" 15" 15" 12" <br /> Bucket Depth: 12" 12" 12" 12" <br /> Wait time between applying 15 minutes 15 minutes 15 minutes 15 minutes <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 9:30 am 9:30 am 9:30 am 11:30 am <br /> Initial Reading(Rj): 11" 11" 11" 11" <br /> Test End Time(TF): 10:30 am 10:30 am 10:30 am 12:30 pm <br /> Final Reading(RF): 11" 11" 11" 111. <br /> Test Duration(TF—Tj): 1 hour 1 hour 1 hour 1 hour <br /> Change in Reading(RF-Rj): 0 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Test Result: ® Pass ❑Fail N Pass ❑Fail 91 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 5 14 2 0 1 5 <br /> j 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 />