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REGLiVEL <br /> SWRC <br /> Spill Bucket Testing Report Form <br /> NOV 0 'January 2006 <br /> � <br /> This form is intended for use by contractors performing annual testing of UST spill containme orm and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submitt A <br /> ency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: LODI MEMORIAL HOSPITAL I Date of Testing: 10/8/2015 <br /> Facility Address: 975 S. FAIRMONT AVENUE LODI, CA 95240 <br /> Facility Contact: RANDY Phone: <br /> Date Local Agency Was Notified of Testing:9/22/2015 <br /> Name of Local Agency Inspector(ifpresent during testing): ARIS AND ELENA <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 n1 Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ® Zane A.Nimmo ❑ David A. Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 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 /> ,. , <br /> Ide;itify Spill Bucket(By Tank 1 FRONT DIESEL 2 3VPH- 4 V P H-DIESEL s <br /> Number, Stored Product, etc.) ALTERNATE <br /> Bucket Installation Type: <br /> ®Direct Bury ❑Direct Bury ElDirect Bury E]Direct Bury <br /> ❑ ® Contained in ® Contained inContained in Sump ❑Contained in Sump Sump Sump <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 0840 1015 1025 <br /> Initial Reading(RI): 12 13 13 <br /> Test End Time(TF): 0940 1115 1125 <br /> Final Reading(RF): 12 13 13 <br /> Test Duration(TF-Ti): HR HR HR HR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: -- -- -- -- <br /> Test Result. Pass ❑Fail ❑ ;Pass ❑Fail Z Pass ❑Fail 0 Pass E]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 /> Technician's Signature '- E `-" Date:-10-8-15 <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 />