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m <br />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: SAN JOAQUIN HOSPITAL I Date of Testing: 08-21-17 <br />Facility Address: 500 W HOSPITAL RD FRENCH CAMP CALIFORNIA 95231 <br />Facility Contact: NORM Phone: <br />Date Local Agency Was Notified of Testing: 8-29-17 <br />Name of Local Agency Inspector (f present during testing): SAN JOAQUIN CO <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Ed Stearns ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez <br />8184188 8211269 5263373 -UT 5273934 -UT <br />Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />® Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: <br />1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 RED DIE <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />[:1 Direct Bury <br />®Contained in Sump <br />F] Direct Bury <br />❑Contained in Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />Bucket Depth: <br />15 <br />Wait time between applying <br />vacuum/water and start of test:" <br />_ <br />Test Start Time (Ti): <br />1445 <br />Initial Reading (Rj): <br />14 <br />Test End Time (TF): <br />1445 <br />Final Reading (RF): <br />14ELI <br />TL <br />Test Duration (TF — Ti): <br />I HOUR <br />Change in Reading (RF - Ri): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />® Pass ❑ Fail <br />El Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />OPW BUCKET <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: Date:08-21-17 <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 />