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0 <br />SWRCB, January 2006 <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 _ FAC ILTTV INFORMATION <br />Facility Name: KAISER HOSPITAL Date of Testing: 1-10-14 <br />Facility Address: 7373 WEST LANE STOCKTON CA <br />Facility Contact: I Phone: <br />Date Local Agency Was Notified of Testing :12-10-13 <br />Name of Local Agency Inspector (if present during testing): SAN JOAQUIN CO <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2ad 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 />N Credentials': ® ICC Service Tech. ® SWRCB Tank Tester I <br />3_ CPILL RTTC KF,T TFSTTNG INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: 1/16 <br />M, <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />MIFWMIMWMMTMMM�� <br />1 DIESEL <br />11,2M, <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />El Contained in Sump <br />❑ Direct Bury <br />El Contained in Sump <br />❑ Direct Bury <br />F1 Contained in <br />Sump <br />❑ Direct Bury <br />F-1 Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />Bucket Depth: <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />Test Start Time (TI): <br />935 <br />Initial Reading (RI): <br />14 <br />Test End Time (TF): <br />1035 <br />Final Reading (RF): <br />14 <br />Test Duration (TF — Tj): <br />1 HOUR <br />Change in Reading (RF - RI): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />_ <br />Test Result: <br />® <br />Pass O <br />Fait <br />❑ <br />Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ <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:01-10-14 <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 />