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SWRCB, January 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: Facility Address: 1501 N Jacktone Rd. Facility Contact: Manager Phone: Date Local Agency Was Notified of Testing :04/27/2016IL Name of Local Agency Inspector (ifpresent during testing): Elena Manzo 2. TESTING CONTRACTOR INFORMATION JUN 0 3 2016 Company Name: Jones Covey Group, Ina Technician Conducting Test: Issac Garcia Credentials: X CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) License Number(s): A,B and Haz 804431 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. 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 Bio Diesel 2 3 4 Bucket Installation Type: ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury lr Contained in Sump ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sum Bucket Diameter: 12" Bucket Depth: 12" Wait time between applying vacuum/water and start of test: 15 minutes Test Start Time (Ti): 11:30am Initial Reading (RI): 11" Test End Time (TF): 12:30 pm Final Reading (RF): 11" Test Duration (TF — TI): 1 hour Change in Reading (RF - Ri): 0 Pass/Fail Threshold or Criteria: 0 Test Result. ®Pass #'Farl1 Pass y,.p Fail Pass,= ❑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 onin this report is true, accurate, and in full compliance with legal requirements. 05/06/2016 Technician's Signature:^ Date: State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.