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D <br /> ..GIFIVED <br /> -( B,January 2006 <br /> Sy�RC <br /> Spill Bucket Testing Report Form ` 'v I ATC <br /> This form is intended for use by contractors performing annual testing of UST spill c � �trsthl form and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator or su mREPARTMETF8 <br /> o to e a P ency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: SUTTER TRACY HOSPITAL Date of Testing: 11/17/17 <br /> Facility Address: 1420 N TRACY BLVD TRACY,CA <br /> Facility Contact: PEDRO Phone: 209-832-6032 <br /> Date Local Agency Was Notified of Testing:11/16/17 <br /> Name of Local Agency Inspector(if present during testing): <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: ®Ed Stearns ❑Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 5250492-UT 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 Equipment Resolution: 1/16 <br /> ----------------- <br /> Identify Spill Bucket(By Tank 1 DSL 2 3 4 <br /> Number,Stored Product, etc. <br /> ®Direct Bury ❑Direct Bury ❑ Direct Bury ❑Direct Bury <br /> Bucket Installation Type: El Contained in Sump ❑ Contained in Sump El Contained in El Contained in <br /> Sump Sum <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): 1230 <br /> Initial Reading(Ri): 12 <br /> Test End Time(TF): 1330 <br /> Final Reading(RF): 12 <br /> Test Duration(TF—Ti): IHR <br /> Change in Reading(RF-Ri): 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: E Pass ❑Fail ❑ Pass ❑Fail ❑ bass ❑Fail ❑ Pass ❑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: c'f' - = Date:I l/17/17 <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 />