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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: SIERRA ENERGY # 15 1 Date of Testing: 5/11/2017 <br /> Facility Address: 400 S. AUBURN STREET COLFAX , CA 95713 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:4/21/2017 — <br /> Name of Local Agency Inspector(rf present during testing): JESSICA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 n1 Street Galt,CA 95632 (209)744-0112 Faz:,(2,, Z�3�{"t6 <br /> Technician Conducting Test: ❑ Ed Stearns E Zane A.Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br /> 8184188 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 —7-9 <br /> 91 4 DIESEL <br /> Number, .Stored Product, etc.) <br /> ® Direct Bury ❑ Direct Bury ® Direct Bury ® Direct Bury <br /> Bucket Installation Type: El Contained in ❑Contained in <br /> ❑ Contained in Sump El Contained in Sump Sum Sum <br /> Bucket Diameter: 11 11 I 1 <br /> Bucket Depth: 13 3/4 13 1/4 14 1/4 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1400 1400 1400 <br /> Initial Reading(RI): 12 1/2 12 1/8 12 1/2 <br /> Test End Time(TF): 1500 1500 1500 <br /> Final Reading(RF): 2 12 1/8 12 1/2 <br /> Test Duration(TF—Ti): HR HR HR HR <br /> Change in Reading(RF-Ri): -10 1/2 0 0 <br /> Pass/Fail Threshold or NO LOSS ALLOWED NO LOSS ALLOWED <br /> Criteria: <br /> Test Result: ❑ Pass ® Fail ❑ Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> 87 SPILL BUCKET FAILED IMMEDIATELY. NO CONTAINMENT LEFT <br /> MUST REPLACE AND RETEST <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 /> —9 <br /> Technician's Signature a 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 />