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;D <br /> R@CENS CE,January 2006 <br /> Spill Bucket Testing Report FormNOV 14 2016 , <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 (f applicable), should be provided to the facility owner/operator for submittal to the local re ujgt agency. <br /> 1. FACILITY INFORMATION ENVIRONMENTia <br /> Facility Name: SUTTER TRACY HOSPITAL I Date oP1rcFtfnW 11-4-16 <br /> Facility Address: 1420 TRACY BLVD TRACY, CA 95376 <br /> Facility Contact: PEDRO Phone: <br /> Date Local Agency Was Notified of Testing:10-20-16 <br /> Name of Local Agency Inspector(fpresent during testing): VICKI <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: ❑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. 0 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 /> Identify Spill Bucket(By Tank 1 2 3 4 DIESEL <br /> Number, Stored Product, etc.) <br /> ❑Direct Bury F]Direct Bury <br /> ❑Direct Bury ® Direct Bury <br /> Bucket Installation Type: ❑Contained in Q Contained in <br /> ❑ Contained in Sump ❑Contained in Sump SumpSum <br /> Bucket Diameter: 11 <br /> Bucket Depth: 12 1/2 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 11 <br /> Initial Reading(Ri): 12 <br /> Test End Time(TF): 12 <br /> Final Reading(RF): 12 <br /> Test Duration(TF—TI): HR HR HR HR <br /> Change in Reading(RF-RI): 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ❑ Pass Q Fail Q Pass Q,Fail ❑ Pass Q Tail ® Pass ❑ Fait <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 W Date: 11-4-16 <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 />