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fforda - Tet 416 2nl Street Phone : (209) 744- 0112 LINE & LEAK DETECTOR <br /> Galt, Ca 95632 Fax : (209) 744-0116 TEST REPORT <br /> affords@softcom . net <br /> CONTRACTOR/ENGINEER TEST DATE 10 / 16 / 18 <br /> SITE NAME LODI MEMORIAL HOSPITAL PHONE (209 ) 339 - 7667 <br /> SITE ADDRESS 975 FAIRMONT AVE CITY LODI <br /> Repair/Construction LOCATION SKETCH Show North <br /> ® Compliance <br /> Insurance <br /> Escrow <br /> Make & Type of Pump or Dispenser <br /> RED JACKET JAN 0 8 2019 <br /> Cover Over Lines <br /> CONCRETEEsti <ilj U , ;U ::. NTAL <br /> Approx Burial Depth <br /> 36' <br /> Weather <br /> WARM <br /> ® Pressure Suction SHOW STREETS , BLDGS , TANKS , ISLANDS , PIPING (IF KNOWN ), PUMPS OR DISPENSERS <br /> Calibrate <br /> LEAK DETECTOR FTA LEAK DETECTOR TEST INFORMATION 10 PSI <br /> Opening Test Leak I Element <br /> KEY TYPES No/ LD Serial Resiliency Time In Rate Holding Metering Pass/ <br /> Product Ke Number Seconds MUMin . 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 STPMLD. D/ E Notes : <br /> CONTRACTOR LINE TEST RESULTS <br /> CERTIFICATION <br /> Technician : Tests were made on the line systems as noted in accordance with test procedures <br /> l ; <br /> prescribed for as detailed on the test chart on Side 2 of this form with results as follows : <br /> DAVE WINKLER LINE IDENTIFICATION NET VOLUME CHANGE PER HOUR <br /> PETROTITE CERT. # : DIE PASS . 0020 <br /> CCA : 5273934-ut <br /> OTTL License # : 08- 174011 <br /> Trainee : PASS / FAIL / INCONCLUSIVE <br /> PASS / FAIL / INCONCLUSIVE <br /> EQUIPNIENT: PETRO TITE LINE TESTER <br />