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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 fibrin and <br /> printouts from tests (if applicable), should be provided to the facility owner/operator.for submittal to the local regulatory agen(y. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SAN JOAQUIN HOSPITAL Date of Testing: 08-31-10 <br /> Facility Address: 500 W HOSPITAL RD FRENCH CAMP CALIFORNIA <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(rf present during testing): MICHELLE HERNY 143 _ <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 ment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank l RED DIE 2 3 4 <br /> Number, Stored Product, etc.) _— <br /> El Direct Bury F-1 Direct Bury <br /> Bucket Installation Type: ElDirect Bury F-1Direct Bury <br /> ® Contained in Sump F-1Contained in Sump El Contained in El Contained in <br /> Sump Sum <br /> Bucket Diameter: 1 I <br /> Bucket Depth: 15 <br /> Wait time between applying _ <br /> vacuum/water and start of test: ----- <br /> Test Start Time(Ti): 200 <br /> Initial Reading(Rj): 14 1/8 _ <br /> Test End Time(TF): 300 <br /> Final Reading(RF): 14 1/8 <br /> Test Duration(TF-Ti): 1 HOUR <br /> Change in Reading(RF-Rj): 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:8/31/10 <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 />