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0 • <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: 0 5 14 2 0 1 5 <br /> Facility Address: 1501 N Jacktone Rd <br /> Facility Contact: Manager Phone: P .� <br /> Date Local Agency Was Notified of Testing:4/16/15 ra, r ti <br /> Name of Local Agency Inspector(f present during testing): Elena Manzo <br /> JUN j <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Jones Covey Group,Inc. AV'' J�� <br /> NMA <br /> Technician Conducting Test: Issac Garcia <br /> Credentials': A CSLB Contractor 9 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: X Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc. T5 91 T6 Auto Diesel <br /> Bucket Installation Type: ]Direct Bury k Direct Bury ❑Direct Bury ❑Direct Bury <br /> Contained in Sump ❑Contained in Sum ❑Contained in Sum ❑Contained in Sum <br /> Bucket Diameter: 12" 12" <br /> Bucket Depth. 12" 12" <br /> Wait time between applying 15 minutes 15 minutes <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 2:00 pm 2:00 pm <br /> Initial Reading(RI): 11" 11" <br /> Test End Time(TF): 3:00 pm 3:00 pm <br /> Final Reading(RF): 11" 11" <br /> Test Duration(TF—Ti): 1 hour 1 hour <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or 0 0 <br /> Criteria: <br /> Test Result: ® Pass ❑Fail N 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 5 14 2 0 1 5 <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 />