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416 2"d Street Phone:(209)744-0112 LINE & LEAK DETECTOR <br /> u"'Aj*t*da','—Te Galt,Ca 95632 Fax:(209)744-0116 TEST REPORT <br /> afforda@softeom.net <br /> CONTRACTOR/ENGINEER TEST DATE 10/8/2015 <br /> SITE: LODI MEMORIAL HOSPITAL <br /> 975 S. FAIRMONT AVE. LODI , CA 95240 <br /> Repair/Construction LOCATION SKETCH Show North <br /> ® Compliance®Owners Request <br /> ❑ Insurance ❑ Escrow SHOW STREETS,BLDGS,TANKS,ISLANDS,PIPING(IF KNOWN),PUMPS OR DISPENSERS <br /> ® Other GENERATOR HLUAVED <br /> Make&Type of Pump or Dispenser <br /> RED JACKET <br /> Cover Over Lines NOV 0 5 2015 <br /> CONCRETE <br /> Approx Burial Depth ENVIRONMENTAL <br /> 2 - 3 FEET qFAITW nPoaQT PNT <br /> Weather <br /> SUNNY, COOL <br /> Pressure ® Suction ❑ <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 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:P L L D - UNTESTED <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 /> OTTL License#: 04-1676 <br /> PETROTITE CERT. [-]PASS ❑FAIL ❑INCONCLUSIVE <br /> #:CCA0202112304R V P H -LINE .0000 <br /> ICC# 5263322 UT ®PASS ❑FAIL E]INCONCLUSIVE <br /> Trainee:NIC GRAHAM [-]PASS ❑FAIL ❑INCONCLUSIVE <br /> [-]PASS ❑FAIL ❑INCONCLUSIVE <br /> EQUIPMENT: PETRO TITE LINE ❑PASS ❑FAIL ❑INCONCLUSIVE <br /> TESTER <br /> Notes: <br />