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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: SAN JOAQUIN HOSPITAL Date of Testing: 08-24-12 <br /> Facility Address: 500 W HOSPITAL RD FRENCH CAMP CALIFORNIA <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing:8-22-12 <br /> Name of Local Agency Inspector(f present during testing): Thuy <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162"d 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/H2O Equipment Resolution: 1/16 <br /> �.... a.�ti 3i ,,,,,,,;. ..�._✓ir .,,.....w��s s,o' .�,..:... r.'3.:.ti::fW/U O.�-\"'M7 <br /> .. ..... .t._.> — 77,77, r., . 77.77. <br /> Identify Spill Bucket(By Tank 1 RED DIE 2 3 4 <br /> Number, Stored Product, etc. <br /> Direct Bury E]Direct Bury <br /> Bucket Installation Type: ❑Direct Bury El Direct Bury ❑Contained in E]Contained in <br /> ®Contained in Sump ❑Contained in Sump Sump Sum <br /> Bucket Diameter: 11 <br /> Bucket Depth: 15 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 1150 <br /> Initial Reading(RI): 133/4 <br /> Test End Time(TF): 1250 <br /> Final Reading(RF): 133/4 <br /> Test Duration(TF—TI): 1 HOUR <br /> Change in Reading(RF-RI): 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 /> 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:08-24-12 <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 />