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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: Pilot Flying J 617 Date of Testing: 5 2 2 0 1 3 <br /> Facility Address: 15100 N. Thornton Road Lodi CA 95242 <br /> Facility Contact: Holly Marlowe Phone: 339-4066 <br /> Date Local Agency Was Notified of Testing: 4/10/13 <br /> Name of Local Agency Inspector(if present during testing): Aris Cacapit <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Jones Covey Group,Inc. <br /> Technician Conducting Test: Daniel Visser <br /> Credentials': FX CSLB Contractor ❑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: ❑Hydrostatic ❑Vacuum 9 Other <br /> Test Equipment Used: Tape Equipment Resolution: Visual <br /> �.., ,. ., <br /> Identify Spill Bucket(By Tank I 2 3 4 <br /> Number, Stored Product, etc. 91#5 FB-VB <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> ©Contained in Sump ❑Contained in Sum2 ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" 12" <br /> Bucket Depth: 12" 12" <br /> Wait time between applying 15Min. 15Min. <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 100 100 <br /> Initial Reading(Ri): 11" 11" <br /> Test End Time(TF): 200 200 <br /> Final Reading(RF): 11" 11" <br /> Test Duration(TF—TI): 1 Hr 1 Hr <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass/Fail Threshold or 0 0 <br /> Criteria: <br /> Test Result: ® Pass 0 Fail ❑'Pass R Fail D Pass ®Fail ❑ Pass', N 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 /> � y <br /> Technician's Signature: Date: 5 2 2 0 1 3 <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 />