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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(f 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: <br /> Facility Address: 15100 N Thornton Rd <br /> Facility Contact: Manager Phone: <br /> Date Local Agency Was Notified of Testing:5/8/2014 <br /> Name of Local Agency Inspector(f present during testing): Aris <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Jones Covey Group,Inc. <br /> Technician Conducting Test: Issac Garcia <br /> Credentials': ®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 ❑Other <br /> Test Equipment Used: Tape Equipment Resolution: Visual <br /> a ... .,...... <br /> Identify Spill Bucket(By Tank 1 T5 91 2 3 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" <br /> Bucket Depth: 12" <br /> Wait time between applying 30 minutes <br /> vacuum/water and start of test: <br /> IL Nm'VMW <br /> Test Start Time(TI): 9:30 am <br /> Initial Reading(RI): 11" <br /> ZC 14 <br /> Test End Time(TF): 10:30 am <br /> Final Reading(RF): <br /> 11" <br /> Test Duration(TF—Tj): 1 hour rkffl:NIT <br /> Change in Reading(RF-RI): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Test Result. 0 Pass 0 Fall 0 Pass OF D Pass ❑Fail © Pass ❑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 /> 5/15/2014 <br /> Technician's Signature: Date: <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 />