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n <br /> S W RCS,°Jarti`uary"20 <br /> Spill Bucket Testing Report Form NOV 10, 2014 <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 submitt �i t l ihr gulcr ry agency. <br /> 1. FACILITY INFORMATION L <br /> Facility Name: LODI MEMORIAL HOSPITAL Date of Testing: 10-09-14 <br /> Facility Address: 9755 FAIRMONT AVE LODI CALIFORINIA <br /> Facility Contact: RANDY Phone: 209-339-7667 <br /> Date Local Agency Was Notified of Testing:9-18-14 <br /> Name of Local Agency Inspector(f present during testing): SAN JOAQUIN CO JEFF <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 1 DIESEL RF 2 A BUCKET 3 DIESEL SO 4 <br /> Number, Stored Product, etc. <br /> ❑Direct Bury El Direct Bury Direct Bury Direct Bury <br /> Bucket Installation Type: ❑ <br /> ®Contained in Sump ®Contained in Sump E]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): 915 915 1030 <br /> Initial Reading(RI): 13 13 12 <br /> Test End Time(TF): 1015 1015 1130 <br /> Final Reading(RF): 13 13 12 <br /> Test Duration(TF—TI): 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ®,Pass ❑Fair Z Pass []Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW 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:10-09-14 <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 />