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• • <br /> Form 12/2404 <br /> Page 2 of 2 <br /> Bucket: bucket: Bucket: Bucket: <br /> Bucket Diameter- <br /> Bucket Depth: f <br /> Wait time between applying <br /> pressure/vacuum/water and <br /> starting test: <br /> Test Start Time: <br /> Initial Reading(Rj)_ <br /> Test End Time: <br /> Final Reading(RF): <br /> Test Duration: <br /> Change in Reading(R,TR,): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: a Pays ❑Fail d Pass ❑Fail © Pass ❑Fsi] n Pass ❑Fail <br /> Comments----(include information on repairs made prior to te.Sting; and recommended follow-up for ailed tests) <br /> CERTIF'ICA'TION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the hw of ney knowledge,the stated' )tis docuare accu and in full compliance with legal regturementr <br /> Technician's Signature: Date:-6/17/05— <br /> Technician's <br /> ate: 6117105Technician's Printed Name:David L_ Mark- __ Company:Franzen-Hill <br />