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Afforda-Te$t Spill Bucket <br /> 416 2nd Street 209 744-01.12 <br /> Galt, Ca. 95632 FAX 209 744-0116 Test Report <br /> 1. FACILITY INFORMATION <br /> Facility Name: 1 Na� <br /> ng:FacilityAddress: d� ( �-Facility Contact: Pho _. <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(zfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: y 1 <br /> Credentialsl: ❑CSLB Contractor C Service Tech. A-SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): LI _ � ) I <br /> -- <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: /-.� .� `t, , _u t , P. <br /> 1 "f ,,. Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 ' ' 2 3 <br /> Number, Stored Product, etc. I 4 <br /> Bucket Installation Type: erect Buryec ury ❑Direct Bury ❑Direct Bury <br /> Bucket Diameter: <br /> ElContained in Su 11Contained in SUMP ❑Contained in Su ❑Contained in S <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: r¢ ' <br /> Test Start Time(Tj): <br /> Initial Reading(RI): e <br /> Test End Time(TF): - .Q.,r <br /> Final Reading(RF): a, y y <br /> Test Duration(TF-TI): , <br /> Change in Reading(RF-RI): <br /> Pass/Fail Threshold or <br /> Criteria: rjjei�iR <br /> esult: ❑.Pass G Fail ❑ Pass Q F <br /> Com ail ❑ Pass ❑Fail ❑ Pass FJ Fail II <br /> Comments - include in - -- -- - —_ <br /> ( information made,prior toing, and recommended folloin-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: ,I,t � _;� <br /> Date: - 75- <br /> - 4D 4. <br />