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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 Date of Testing: 10-09-13 <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(if present during testing): SAN JOAQUIN CO Thuy <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2id 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 Direct Bury <br /> Bucket Installation Type: F-1 Direct Bury r-1 Direct Bury ❑Contained in F1 Contained in <br /> ®Contained in Sump ®Contained in Sump Sump 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): 915 915 915 <br /> Initial Reading(RI): 13 13 12 <br /> Test End Time(TF): 1015 1015 1015 <br /> Final Reading(RF): 13 13 12 <br /> Test Duration(TF—Tt): 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or _ _ <br /> Criteria <br /> kit W� <br /> Comments—(include information on repairs made prior to testing, and recommendedfollow <br /> 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:10-09-13 <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 />