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fforda416 2 Street Phone:(209)744-0112 LINE & LEAK DETECTOR <br /> Galt,Ca 95632 Fax:(209)744-0116 TEST REPORT <br /> afforda@softcom.net <br /> CONTRACTOR/ENGINEER TEST DATE 10/22/19 <br /> SITE: LODI MEMORIAL HOSPITAL <br /> 975 S. FAIRMONT LODI, CA 95240 <br /> ❑ Repair/Construction LOCATION SKETCH snow North <br /> ® Compliance❑ Owners Request <br /> ❑ Insurance ❑ Escrow SHOW STREETS,BLDGS,TANKS,ISLANDS,PIPING(IF KNOWN),PUMPS OR DISPENSERS <br /> ® Other IN LUE OF <br /> SHUTDOWN <br /> Make&Type of Pump or Dispenser <br /> RED JACKET <br /> Cover Over Lines <br /> CONCRETE <br /> Approx Burial Depth <br /> 3-5 FT <br /> Weather <br /> SUNNY COOL <br /> Pressure ® Suction ❑ <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 Key Number Seconds ML/Min. PSI PSI Fail <br /> A LD 2000 <br /> B LD 2000 E <br /> C FXI V <br /> D FX1 DV <br /> E STPMLD <br /> F STPMLD — D <br /> G STPMLD — E <br /> H I STPMLD—D/E Notes: <br /> CONTRACTOR <br /> CERTIFICATION LINE TEST RESULTS <br /> Technician: Tests were made on the line systems as noted in accordance with test procedures <br /> Ed Stearns prescribed for as detailed on the test chart on Side 2 of this form with results as follows: <br /> LINE IDENTIFICATION - NET VOLUME CHANGE PER HOUR <br /> PETROTITE CERT.#: []PASS ❑FAIL ❑INCONCLUSIVE <br /> ICC#8883080-UT RED DIESEL 0.010 <br /> OTTL License#: ®PASS ❑FAIL ❑INCONCLUSIVE <br /> Trainee: [—]PASS ❑FAIL ❑INCONCLUSIVE <br /> [—]PASS ❑FAIL ❑INCONCLUSIVE <br /> EQUIPMENT: PETRO TITE LINE ❑PASS ❑FAIL ❑INCONCLUSIVE <br /> TESTER <br />