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416 2"d Street Phone:(209)744-0112 LINE & LEAK DETECTOR <br /> Lfftorda—Te$t Galt,Ca 95632 Fax:(209)744-0116 TEST REPORT <br /> afforda@softcom.net <br /> CONTRACTOR/ENGINEER TEST DATE 10/6/2016 <br /> SITE: LODI MEMORIAL HOSPITAL <br /> 975 S. FAIRMONT AVE. LODI, CA 95240 <br /> Repair/Construction LOCATION SKETCH Show North <br /> ® Compliance ® Owners Request <br /> Insurance ❑ Escrow SHOW STREETS,BLDGS,TANKS,ISLANDS,PIPING(IF KNOWN),PUMPS OR DISPENSERS <br /> ® Other GENERATOR <br /> Make&Type of Pump or Dispenser <br /> RED JACKET RECEIVED <br /> Cover Over Lines <br /> CONCRETE No"T 17 2016 <br /> Approx Burial Depth EINIRONMEN TAL HEALTH <br /> 2 - 3 FEETPERMIT/SERVICES <br /> Weather <br /> SUNNY, COOL <br /> Pressure Suction <br /> Calibrate <br /> LEAK DETECTOR FTA LEAK DETECTOR TEST INFORMATION 10 PSI <br /> Opening Test Leak 1 Element <br /> KEY TYPES No/ LD Serial Resiliency Time In Rate Holding Metering Pass/ <br /> Product Key Number Seconds M1JMin. PSI PSI Fail <br /> ~ A LD 2000 <br /> B LD 2000 E <br /> C FXI V <br /> D FXI DV <br /> E STPMLD <br /> F STPMLD — D <br /> G STPMLD — E <br /> H I STPMLD—D/E Notesf L L D -UNTESTED <br /> CONTRACTOR <br /> CERTIFICATION LINE TEST RESULTS <br /> Technician: Tests were made on the line systems as noted in accordance with test procedures <br /> Zane A.Nimmo prescribed for as detailed on the test chart on Side 2 of this form with results as follows: <br /> LINE IDENTIFICATION NET VOLUME CHANGE PER HOUR <br /> OTTL License#: 04-1676 <br /> PETROTITE CERT. ❑PASS [-]FAIL ❑INCONCLUSIVE <br /> #:CCA0202112304R V P H - LINE -.0020 <br /> ICC# 5263322 UT ®PASS ❑FAIL [-I INCONCLUSIVE <br /> Trainee:GORDON BICE CIPASS ❑FAIL ❑INCONCLUSIVE <br /> []PASS ❑FAIL ❑INCONCLUSIVE <br /> EQUIPMENT: PETRO TITE LINE <br /> [-]PASS []FAIL PASS FAIL INCONCLUSIVE <br /> Notes: <br />