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Afforda-Te$t Spill Bucket <br /> 416 2nd Street 209 744-0112 Test Deport <br /> Galt, Ca. 95632 FAX 209 744-0116 <br /> 1. FACILITY INFORMATION <br /> Facility Name: fJ- Date of Testing: - "a/-p� <br /> Facility Address: U <br /> Facility Contact: S',,, "� Phone: <br /> Date Local Agency Was Nott ied of Testing: - /(n Q(o 0 "n e t,r 5 <br /> Name of Local Agency Inspector(if present during testing): T-t y' ot G u 4 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: F7- u r <br /> Technician Conducting Test: j , , , „t „„1 <br /> Credentials: ❑CSLB Contractor �S'ervice Tech. ®'S kCB Tank Tester ❑Other(Spec) <br /> License Number(s): ( - (/ <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: 2-Hydrostatic ❑!Vacuum ❑Other <br /> Test Equipment Used: a, "J.i=1 A,ea c u r �`7 0 ! � 0�1' i� - Equipment Resolution: //6,y <br /> Identify Spill Bucket(By Tank 1 2 ,r'} 3 4 <br /> Number,Stored Product, etc. � tl 1' <br /> Bucket Installation Type: ErDirect Bury irect Bury - ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump 11 Contained in Sump <br /> Bucket Diameter: ) / ;L, <br /> Bucket Depth: - <br /> Wait time between applying <br /> vacuum/water and start of test: --e!r <br /> Test Start Time(Ti): �- <br /> Initial Reading(Ri): 76C�!- L1 w c <br /> Test End Time(TF): �c -5 <br /> Final Reading(RF): - <br /> Test Duration(TF-TO: <br /> Change in Reading(RF-RO: - <br /> Pass/Fail Tbreshold or <br /> Criteria: <br /> Comments-(include information on repairs made pri®rto testing and recommended follow up for failed tests) <br /> CERTIFICATION OF TECIINICIAN RESPONSIBLE FOR CONDUCTING TIIIS TESTING <br /> I hereby certify that all the information.contained inthis report is true,accurate,and in full compliance with legal requirements. <br /> / / <br /> Technician's Signature: 'w//; j :�.//,LL' Date: <br />