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0 C T 17 W CB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill con M1 ` W#0rm and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submitQ latory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: LODI MEMORIAL HOSPITAL I Date of Testing: 10/6/2016 <br /> Facility Address: 975 S. FAIRMONT AVENUE LODI, CA 95240 <br /> Facility Contact: RANDY Phone: <br /> Date Local Agency Was Notified of Testing:9/24/2016 <br /> Name of Local Agency Inspector(af present during testing): FATINAH <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2°a 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 MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 FRONT DIESEL 2 3 VPH- 4 V P H-DIESEL <br /> Number,Stored Product, etc.) ALTERNATE <br /> ®Direct Bury ❑Direct Bury <br /> ❑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: 13 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1110 1210 1210 <br /> Initial Reading(RI): 12 13 13 <br /> Test End Time(TF): 1210 1310 1310 <br /> Final Reading(RF): 12 13 13 <br /> Test Duration(TF—Ti): HR HR HR HR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: - <br /> Test Result: Pass ❑Fail Pass ❑Fain Pass', ❑Fail Z P ❑Fael <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <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:-10-6-16 <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 />