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Form 12/2004 <br /> Page 2 of 2 <br /> Bucket. Bucket. Bucket: Bucket: <br /> Bucket Diameter: <br /> Bucket Depth: <br /> Wait time between applying <br /> pressure/vacuum/water and <br /> starting test: <br /> Test-Start Time: <br /> initial Reading A): <br /> Test End Time: <br /> Final Readins CRF): <br /> Test Duration: <br /> Change in Reading(RFRI): <br /> PassfFail TbTeshold or <br /> Criteria: <br /> Test Result; 0 Pass 0 Fail [I Pass ❑Fail ❑ Pass 0 Fail 0 Pass 0 Fail <br /> Comments—(include information on re czars made riot t0 resting, and recarnrnended ollorv- or ailed tests <br /> CF <br /> RTlplCATION OF TECHMCL&,N REsPONSMLE FOR CONDUCTING TMS TESTING <br /> To the best of my knowledge,the stated i his docanI are accur ta'and infull complirurce with legal requirements <br /> : J <br /> Technician's-Signature; Date:-6/17/05— <br /> Technician's <br /> ate:_b/17105_Technician's Printed Name:David L.Martin Company:Franzen-Hill <br />