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L L' SWRCB, January 2006 Spill Bucket Testing Report Form JUN 0 3 2016 This form is intended for use by contractors performing annual testing of UST spill containment e completed form and printouts from tests (if applicable), should be provided to the facility owner/operator for submWial `tb thecal 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: Phone: Date Local Agency Was Notified of Testing :04/27/2016 Name of Local Agency Inspector (ifpresent during testing): Elena Manzo 2. TESTING CONTRACTOR INFORMATION Company Name: Jones Covey Group, Inc. Technician Conducting Test: Issac Garcia Credentials': ❑ CSLB Contractor X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) License Number(s): A,B and Haz 804431 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ❑ Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: Equipment Resolution: Identify Spill Bucket (By Tank Number, Stored Product, etc. 1 T5 91 2 T6 Auto Diesel 3 T7 Waste Water 4 Bucket Installation Type: k Direct Bury ❑ Contained in Sump F Direct Bury ❑ Contained in Sump ❑ Direct Bury 9 Contained in Sump ❑ Direct Bury ❑ Contained in Sum Bucket Diameter: 12" 12" 12" Bucket Depth: 12" 12" 12" Wait time between applying vacuum/water and start of test: 15 minutes 15 minutes 15 minutes Test Start Time (T,): 9:30am 9:30am 11:30am Initial Reading (RI): 6.4003 6.6494 11 3/4" Test End Time (TF): 9:45am 9:45am 12:30 pm Final Reading (RF): 6.4007 6.6493 11 3/4" Test Duration (TF — TI): 15 minutes 15 minutes 1 hour Change in Reading (RF - RI): 0.0004 0.0001 0 Pass/Fail Threshold or Criteria: 0.002 0.002 0 �e�t ReSu�t � � Gi""aC5 FaYY �1; Pass"t3 Fail CI Feil „ , , L7 -Pass ;=. fl Fail Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) 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.