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0 10 RECENED <br /> NOV 10 2014 <br /> 416 2nd Street Phone:(209)744-0112 L! 1L <br /> 00 JLj; t ffordaGalt,Ca 95632 Fax: 209 744-0116 <br /> afforda@softcom.net TESD l SANT <br /> CONTRACTOR/ENGINEER TEST DATE 10/09/14 <br /> SITE NAME LODI MEMORIAL HOSPITAL PHONE (209) 339 -7667 <br /> SITE ADDRESS 975 FAIRMONT AVE CITY LODI <br /> Repair/Construction LOCATION SKETCH Show North <br /> ® Compliance <br /> Insurance <br /> Escrow <br /> Make&Type of Pump or Dispenser <br /> REDJACKET <br /> Cover Over Lines <br /> CONCRETE <br /> Approx Burial Depth <br /> 36' <br /> Weather <br /> WINDY <br /> Pressure I Suction SHOW STREETS,BLDGS,TANKS,ISLANDS,PIPING(IF KNOWN),PUMPS OR DISPENSERS <br /> Calibrate <br /> LEAK DETECTOR FTA LEAK DETECTOR TEST INFORMATION 10 PSI <br /> Opening Test Leak I Element <br /> KEY TYPES No/ LD Serial Resiliency Time In Rate Holding Metering Pass/ <br /> Product Key Number Seconds MUMin. PSI PSI Fail <br /> A LD 2000 <br /> B LD 2000 E <br /> C FXI V <br /> D FXI DV <br /> E STPMLD <br /> F STPMLD — D <br /> G STPMLD — E <br /> H STPMLD—D/E Notes: <br /> CONTRACTOR <br /> CERTIFICATION LINE TEST RESULTS <br /> Technician: Tests were made on the line systems as noted in accordance with test procedures <br /> prescribed for as detailed on the test chart on Side 2 of this form with results as follows: <br /> FELIX RAMIREZ LINE IDENTIFICATION NET VOLUME CHANGE PER HOUR <br /> PETROTITE CERT.#: DIE PASS -•0000 <br /> CCA: 5273934-UT <br /> OTTL License#: 08-1740 <br /> Trainee: DIESEL 2 PASS -.0010 <br /> EQUIPMENT: PETRO TITE LINE TESTER <br />