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OREU;tt v E:�Lj <br /> NODI 2 8 2017 <br /> SWRCB2006 <br /> Spill Bucket Testing Report Fo \jI L Ognm <br /> This form is intended for use by contractors performing annual testing of UST spill containment st eted form and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SUTTER TRACY HOSPITAL I Date of Testing: 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(if present during testing): VICKI <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"d 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. ® 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 ®Direct Bury <br /> Bucket Installation Type: El Direct Bury El Direct Bury El Contained in El Contained in <br /> F1 Contained in Sump ❑Contained in Sump SUM2 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): 11 <br /> Initial Reading(R,): 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 ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail E 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 W Date: I1-4-16 <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 />