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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 /> 1.FACILITY INFORMATION <br /> Facility Name: LODI MEMORIAL HOSPITAL I Date of Testing: 10-10-12 <br /> Facility Address: 9755 FAIRMONT AVE LODI CALIFORINIA <br /> Facility Contact: RANDY Phone: 209-339-7667 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(f present during testing): SAN JOAQUIN CO JEFF WONG <br /> 2.TESTING CONTRACTOR INFORMATION <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 /> 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/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank I DIESEL RF 2 A BUCKET 3 DIESEL SO u\ 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: <br /> ElDirect Bury ❑Direct Bury ®Direct Bury E] Direct Bury® Contained in Sump ®Contained in Sump El Contained in ❑ Contained in <br /> Sum Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 14 14 13 <br /> * Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 930 930 930 <br /> Initial Reading(RI): 13 13 12 <br /> Test End Time(TF): 1030 1030 1030 <br /> Final Reading(RF): 1 13 13 12 <br /> Test Duration(TF—Tj): 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or _ <br /> Criteria: - <br /> ` PSss ❑Fay pas afl p P fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> ®PW BUCKETS <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:10-10-12 <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 />