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r . <br /> MAR 3 1 2008 SWPCB,January 2006 <br /> Spill Bucket Testing Repat*i W tlT HEALTH <br /> This form is intended for use by contractors performing annual testing Of UST'spR�Awdusmyj Sures. The completed form and <br /> ,arintouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the tocat regulatory agency, <br /> 1 X i'UMA W <br /> Facility Name: ?G,1 C. D.lite of I esti#ig: 3 <br /> 12410 e <br /> Facility Address: t{ <br /> V4eility,Contact: i U" �-t, ph{rn• 0 Z--7 - <br /> Date Local AgencyWas Notified of Tes ang. <br /> Name of Local Agency Inspector((/'present during tg�•ting):. (i c� <br /> 2. TUB, G.G�I�JIRA .�IN�O ?tt?N <br /> Company Name: <br /> Technician Conducting Test: <br /> Eredentialsi: CSLB Contractor ICC Service_Teeh. C$Ta614 Tester' Othdr(15Pecify). <br /> License Number(s): . D -11 .. . . <br /> 3. <br /> Test Method Used: H a2p'ialic Vvpcutt>� r <br /> Test]3 iprapt sed:Uo l!� k c <br /> pC situ <br /> 2 51-t-o l] Yam �leclsa✓ <br /> IdCntlfy Spill:BnckeeUJ ae3:5WF <br /> (By Tan) l 5 <br /> Number, StoredProduct etc. . . . .tl-T -'�1G- ��'•� „�`� •. <br /> D' ect Bnr Di'reCtSury t'' blrect BnrY nl P trect Bpry <br /> '•Bucket Installation Type: Con ed Ih Su Ccptained:w Sum Ca tamed iii Sum' pritalnEd in.S m <br /> Bucket Diameter:' /off" OC2CJ4X t O <br /> ,j*ket Depth: <br /> azt time b een applying <br /> ater .d Start Of test. . .1,o b rt.-,u4A <br /> ;fesi.StarCTime(T): 12..: 7— <br /> .,lutial Reading(Rj: v4 c.(�re. e:•. P1 v5•�' �'G . . . � i t l .. <br /> :Fest End Time(Te): <br /> "I?itia]Reading(RP): <br /> Gr¢r(Q n 5� LrrG( n <br /> "es[Duration.(Tr-Tt).' 3 D M r pw $ -�•y.0{,�,/✓ <br /> jange in keadmg([ta Rt) N o Gl N d C w <br /> ; <br />