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• <br />Form 12/2004 <br />Page 2 of 2 <br />Bucket; Bucket: Bucket: <br />Bucket Diameter: Bucket: <br />Bucket Deptlt: <br />Wait time between applying <br />pressure/vacuum/water and <br />startin test: <br />Test Stan Time: <br />Initial Reading (R,): <br />Test End Time: <br />Final Reading (RF): <br />Test Duration: <br />Change in Reading (R. -R,). <br />Pass/Fail Threshold or <br />Criteria: <br />Fest Result:' ri laass D Fai► <br />CI.Pass .0 Fail D 1Pass ❑ Fail <br />•. .Pass L7>rail' <br />e011 Meats — (fncfude fn ornuvfon oft <br />made riot ro resrirr ,and recomntentled <br />CERTIFICATION OF TECHNICIAN R ESPONSrBLE FOR CONDLTCTING THIS TESTING <br />x'o the hest of my kno►qedge, the facts stated in this document are accurate and infull compliance with legal requirer encs <br />Technician's Signature: <br />Technician's Printed Name: <br />Date: <br />Company; Franzen -Hill <br />