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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 />FA!'IT.TTV TNFnRMATinN <br />Facility Name: SUTTER TRACY HOSPITAL Date of Testing: 11/2/12 <br />Facility Address: 1420 TRACY BLVD TRACY, CA 95376 <br />Facility Contact: PEDRO Phone: <br />Date Local Agency Was Notified of Testing :10/24/12 <br />Name of Local Agency Inspector (rfpresent during testing): TWI <br />Company Name: AFFORDA TEST 4162 nd 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 />I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester I <br />C 1041 11 4 py IN I W11 • • <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE, H2O <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank 1 <br />Number, Stored Product, etc.) <br />2 <br />3 <br />4 DIESEL <br />❑ Direct Bury <br />Bucket Installation Type: <br />El Contained in Sump <br />❑Direct Bury <br />❑Contained in Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sump <br />® Direct Bury <br />F1 Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />Bucket Depth: <br />12 1/2 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Tj): <br />1305 <br />Initial Reading (RI): <br />11 1/2 <br />Test End Time (TF): <br />1405 <br />Final Reading (RF): <br />11 1/2 <br />Test Duration (TF — TI): <br />HR <br />HR <br />HR <br />HR <br />Change in Reading (RF - RI): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />til ElPass'. �, C11�- '.) Pass : ❑ 1iI" Pass ; ❑ )�ai� ' <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 SignatureDate: I1-2-12 <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 />