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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(f 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: 10-26-17 <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(if present during testing): SAN JOAQUIN CO BETTY HO <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd 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 /> Identify Spill Bucket (By Tank 1 DIESEL 2 NOT USED 3 DIESEL 4 <br /> Number, Stored Product, etc.2 REMOTE <br /> ❑Direct Bury ❑Direct Bury ®Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ®Contained in Sump ®Contained in Sump ❑Contained in ❑ Contained in <br /> Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth. 15 15 14 ��` "' 7 p <br /> Wait time between applying _ _ <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 900 900 900 <br /> Initial Reading(RI): 14 14 13 <br /> Test End Time(TF): 1000 1000 1000 � r T <br /> Final Reading(RF): 14 14 13 F NT <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 ❑Fail ® 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:10-26-17 <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 />