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urda."le <br />ALfo I tt <br />4162 nd Street Phone: (209) 744-0112 <br />Galt, Ca 95632 Fax: (209) 744-0116 <br />afforda@softcom.net <br />LINE & LEAK DETECTOR <br />TEST REPORT <br />CONTRACTOR/ENGINEER <br />TEST DATE 10/11/11 <br />SITE: LODI MEMORIAL HOSPITAL <br />975 S. FAIRMONT AVENUE <br />LODI, CA 95240 <br />Repair/Construction <br />LOCATION SKETCH Show North <br />® Compliance ❑ Owners Request <br />SHOW STREETS, BLDGS, TANKS, ISLANDS, PIPING (IF KNOWN), PUMPS OR DISPENSERS <br />Insurance Lj Escrow <br />Other <br />Make & Type of Pump or Dispenser <br />RED JACKET <br />Cover Over Lines <br />CONCRETE <br />Approx Burial Depth <br />2-4 FT <br />Weather <br />SUNNY, WARM <br />Pressure ® 1 Suction <br />LEAK DETECTOR <br />FTA LEAK DETECTOR TEST INFORMATION <br />Calibrate <br />10 PSI <br />Opening Test Leak I Element <br />KEY TYPES No/ LD Serial Resiliency Time In Rate Holding <br />Product Key Number Seconds MUMin. PSI <br />Metering <br />PSI <br />Pass/ <br />Fall <br />A LD 2000 <br />B LD 2000 E <br />C FXI V <br />D FXI DV <br />E STPMLD <br />F STPMLD — D <br />G STPMLD — E <br />H STPMLD—D/E Notes: <br />CONTRACTOR <br />CERTIFICATION LINE TEST RESULTS <br />Technician: Tests were made on the line systems as noted in accordance with test procedures <br />Zane A.Nimmo prescribed for as detailed on the test chart on Side 2 of this form with results as follows: <br />LINE IDENTIFICATION NET VOLUME CHANGE PER HOUR <br />PETROTITE CERT. <br />#:CCA0202112304R <br />ICC# 5263322 UT <br />OTTL License #: 04-1676 <br />PASS EIFAIL INCONCLUSIVE <br />OLD DIESEL <br />®PASS ❑FAIL ❑ INCONCLUSIVE <br />.0000 <br />Trainee: <br />PASS ❑FAIL ❑ INCONCLUSIVE <br />NEW DIESEL <br />®Pass ❑FAIL ❑ INCONCLUSIVE <br />+.0040 <br />EQUIPMENT: PETRO TITE LINE <br />TESTER <br />[-]PASS ❑FAIL ❑ INCONCLUSIVE <br />