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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: DAMERON HOSPITAL I Date of Testing: 02-01-13 <br /> Facility Address: 525 ACACIA AVE STOCKTON CALIFORNIA <br /> Facility Contact: ALSEHA Phone: 209-944-5550 <br /> Date Local Agency Was Notified of Testing:01-15-13 <br /> Name of Local Agency Inspector(f present during testing): SAN JOAQUIN CO JEFFERY <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 H2O Equipment Resolution: 1/16 <br /> 777 <br /> ,: .... <br /> Identify Spill Bucket(By Tank 1 RED DIE 2 3 4 <br /> Number, Stored Product, etc. <br /> Direct Bury Direct Bury <br /> Bucket Installation Type: ®Direct Bury El Direct Bury El Contained in <br /> ❑Contained in Sum ❑Contained in <br /> Sump El in Sump Sump Sum <br /> Bucket Diameter: 11 <br /> Bucket Depth: 11 <br /> Wait time between applying _ <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 900 <br /> Initial Reading(Rj): 10 1/4 <br /> Test End Time(TF): 1000 <br /> Final Reading(RF): 8 <br /> Test Duration(TF—Ti): 1 HOUR <br /> Change in Reading(RF-RI): 21/4 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Test Result: ❑ Pass Z 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 /> TRIED TO MAKE REPAIRS <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:_ (l - Date:2-1-13 <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 />