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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: Flying J#618 Date of Testing: 0 5 03 2 0 1 7 <br /> Facility Address: 1501 N.Jack Tone Rd. <br /> Facility Contact: Manager Phone:209 599-4141 <br /> Date Local Agency Was Notified of Testing:4.17.17 <br /> Name of Local Agency Inspector(if present during testing): Aron Hang <br /> f <br /> 2. TESTING CONTRACTOR INFORMATION ' - A <br /> Company Name:Jones Covey Group,Inc. <br /> Technician Conducting Test: James Blaine <br /> Credentials': N CSLB Contractor 9 ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): A,B and Haz 804431 .7H <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: N Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution: <br /> nN.ihiANift1 a ��-„ a,:%G�k k^../,;-777w--,�—,, ,7r7 hA;1891 ?..I:EG fM1' ';NSZF. v i <br /> n'nY <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 ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> N Contained in Sump N Contained in Sump N Contained in Sump N Contained in Sump <br /> Bucket Diameter: 15" 18" 18" 12" <br /> Bucket Depth: 12" 11.25" 11.25" 12" <br /> Wait time between applying 15 min 15 min 15 min 15 min <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 11:00am 11:00am 9:30am 9:30am <br /> Initial Reading(RI): 11.5" 11" 11" 11.5" <br /> Test End Time(TF): 12:00pm 12:00pm 10:30am 10:30am <br /> Final Reading(RF): 11.5" 11" 11" 11.5" <br /> Test Duration(TF—TI): 1 hour 1 hour 1 hour 1 hour <br /> Change in Reading(RF-RI): 0 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Test Result: ® Pass ❑Fail 10 Pass ❑Fall ® Pass ❑Fail 9 Pass ❑Fait <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: 0503 2 0 1 7 <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 />