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4162"d Street Phone: (209)744-0112 LINE & LEAK DETECTOR <br /> No r d a—jett Galt,Ca 95632 Fax: (209)744-0116 TEST REPORT <br /> afforda@softcom.net <br /> CONTRACTOR/ENGINEER TEST DATE 10/ 10/ 12 <br /> SITE NAME LODI MEMORIAL HOSPITAL T 19 20 <br /> 92 PHONE (209) 339-7667 <br /> SITE ADDRESS 975 FAIRMONT AVE / CITY LODI <br /> Repair/Construction LOCATION SKE Show North <br /> Pol <br /> ® Compliance S <br /> Insurance <br /> Escrow <br /> Make&Type of Pump or Dispenser <br /> REDJACKET <br /> Cover Over Lines <br /> CONCRETE <br /> Approx Burial Depth <br /> 36' <br /> Weather <br /> WINDY <br /> ® I Pressure Suction ® SHOW STREETS,BLDGS,TANKS,ISLANDS,PIPING(IF KNOWN),PUMPS OR DISPENSERS <br /> Calibrate <br /> LEAK DETECTOR FTA LEAK DETECTOR TEST INFORMATION 10 PSI <br /> Opening Test Leak I Element <br /> KEY TYPES No/ LD Serial Resiliency Time In Rate Holding Metering Pass/ <br /> Product Key Number Seconds ML/Min. PSI PSI Fail <br /> A LD 2000 <br /> B I LD 2000 E <br /> C FXI V <br /> D FXI DV <br /> E STPMLD <br /> F STPMLD — D <br /> G STPMLD — E <br /> H I STPMLD—D/E Notes: <br /> CONTRACTOR LINE TEST RESULTS <br /> CERTIFICATION <br /> Technician: Tests were made on the line systems as noted in accordance with test procedures <br /> 41r®� � <br /> prescribed for as detailed on the test chart on Side 2 of this form with results as follows: <br /> FELIX RAMIREZ LINE IDENTIFICATION NET VOLUME CHANGE PER HOUR <br /> PETROTITE CERT.#: DIE PASS •0010 <br /> CCA: 5273934-ut <br /> OTTL License#: 08-1740 PASS/FAIL/INCONCLUSIVE <br /> Trainee: PASS/FAIL/INCONCLUSIVE <br /> PASS/FAIL/INCONCLUSIVE <br /> EQUIPMENT: PETRO TITE LINE TESTER <br />