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L L 6� - JUN Sumanuary 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Pilot -Flying J #618 Date of Testing: 05/04/2016 Facility Address: 1501 N Jacktone Rd. Facility Contact: Manager Phone: Date Local Agency Was Notified of Testing .04/27/2016 Name of Local Agency Inspector (if present during testing): Elena Manzo 2. TESTING CONTRACTOR INFORMATION Company Name: Jones Covey Group, Inc. Technician Conducting Test: Issac Garcia Credentials': Lr CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) License Number(s): A,B and Haz 804431 3. SPILL BUCKET TESTING INFORMATION Test Method Used: X Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: Equipment Resolution: Identify Spill Bucket (By Tank Number, Stored Product, etc. 1 T1 Diesel 2 3 T2 Diesel T3 Diesel 4 T4 87 Bucket Installation Type: 1W Direct Bury ❑ Contained in Sump L Direct Bury X Direct Bury ❑ Contained in Sump ❑ Contained in Sump X Direct Bury ❑ Contained in Sum Bucket Diameter: 15" 15" 15" 12:30 pm Bucket Depth: 12" 12" 12" 12" Wait time between applying vacuum/water and start of test: 15 minutes 15 minutes 15 minutes 15 minutes Test Start Time (Ti): 6:59pm 6:59pm 2:30pm 9:30am Initial Reading (RI): 6.5175 4.9293 11 5/8" 5.4930 Test End Time (TF): 7:14pm 7:14pm 3:30pm 9:45am Final Reading (RF): 6.5185 4.9281 11 5/8" 5.4928 Test Duration (TF— T,): 15 minutes 15 minutes 1 hour 15 minutes Change in Reading (RF - Rj): 0.0010 0.0012 0 0.0002 Pass/Fail Threshold or Criteria: 0.002 0.002 0 0.002 Test Result; ; . ®P,.,ass l Fail _ , Pass , "❑Fail .. :" Pass":.d Fail pass l Fail . `°' Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) Due to repairs and time constraints, with permission of Inspector T3 spill bucket although a direct bury was tested with use of 1 hour visual method. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: Date: 05/04/2016 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.