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O <br /> NOV 3 0 2017 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing RepolprWgNMENTAL <br /> This form is intended for use by contractors performing annual testing of UST spill conta 'he 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 INFO TION <br /> Facility Name: LODI MEMORIAL HOSPITAL Date of Testing: 10-26-17 <br /> Facility Address: 975 S FAIRMONT LODI CA 95240 <br /> Facility Contact: RANDY Phone: 209-339-7667 <br /> Date Local Agency Was Notified of Testing:09-27-17 <br /> Name of Local Agency Inspector(af present during testing): SAN JOAQUIN CO BETTY HO <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: ❑Ed Sterns ❑ Zane A.Nimmo ❑ David A. Winkler ® Felix G.Ramirez <br /> 814188-UT 8211269-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: <br /> _. <br /> M--M- 777-77-71 <br /> Identify Spill Bucket(By Tank 1 DIESEL 2 NOT USED 3 DIESEL 4 <br /> Number,Stored Product, etc. REMOTE <br /> ❑Direct Bury ❑Direct Bury ®Direct Bury ❑Direct Bury <br /> Bucket Installation Type: [I Contained in El Contained in <br /> t ®Contained in Sump ®Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 15 15 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 900 900 900 <br /> Initial Reading(Ri): 1 14 14 13 <br /> Test End Time(TF): 1000 1000 1000 <br /> Final Reading(RF): 14 14 13 <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 El Fail ® Pass ElFail 0 Pass ElFail ElPass ElFail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> QPW 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:10-26-17 <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 />