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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: SAN JOAQUIN GENERAL HOSPITAL Date of Testing: 8/10/09 <br /> Facility Address: 500 W. HOSPITAL DR. FRENCH CAMP,CA 95231 <br /> Facility Contact: JESSE B. --- BAGLEY Phone: <br /> Date Local Agency Was Notified of Testing:8/4/09 <br /> Name of Local Agency Inspector(f present during testing): MICHELLE HENRY <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd 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 /> ax.g <br /> asQ <br /> Identify Spill Bucket(By Tank I RED DIESEL 2 3 4 <br /> Number, Stored Product, etc.) <br /> F-1DirectBury E] Direct Bury F-1DirectBury E:1 Direct Bury <br /> Bucket Installation Type: ® Contained in Sump ❑ Contained in Sump El Contained in El Contained in <br /> Sump Sum <br /> Bucket Diameter: 11 <br /> Bucket Depth: 13 3/4 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 915 <br /> Initial Reading(Rj): 13 1/4 <br /> Test End Time(TF): 1015 <br /> Final Reading(RF): 13 1/4 <br /> Test Duration(TF—Tl): HOUR <br /> Change in Reading(RF-Rj): 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass El 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 /> 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 O-r04E� Date: 8-10-09 <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 />