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Afforda-Te$ <br />416 ♦' Street <br />Galt, Ca. 95632 <br />w <br />209 744-0112 <br />FAX 209 744-0116 <br />gma= <br />• � i l <br />1. FACILITY INFORMATION <br />FacilityName: Date of Testing: -/ <br />Facility Address: tp�® <br />Facility Contact: d Phone: <br />Date Local Agency Was Notified of Testing: <br />t ` -� <br />Name of Local Agency Inspector (f present during testing): -r ® A <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: � r <br />Technician Conducting Test: ®ISPst r <br />is <br />Credentials': 0 CSLB Contractor 0 ICC Service Tech. JKSWRCB Tank Tester 0 Other <br />License Number(s): �,y 19�1 I / /-� - /A n — ! t Li <br />Bucket Depth: <br />Comments <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />ydrostatic <br />0 Vacuum <br />0 Other <br />Test Equipment Used: <br />A r <br />Test End Time (TF): <br />Final Reading (RF): <br />G' <br />Test Duration (TF - TO: <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />1 <br />2 <br />1 `5z— <br />z- <br />Number, Stored Product, etc. <br />3 q <br />Bucket Installation Type: <br />0 Direct Bury <br />0 Direct Bury <br />0 Direct Bury 0 Direct Bury <br />Bucket Diameter: <br />0 Contained in Sump <br />0 Contained in Sump <br />0 Contained in S ❑Contained in <br />Bucket Depth: <br />Comments <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TO: <br />Initial Reading (RI): <br />A r <br />Test End Time (TF): <br />Final Reading (RF): <br />G' <br />Test Duration (TF - TO: <br />i <br />� <br />Change in Reading (RF - Rt): <br />(REF- <br />Pass/Fail Threshold or <br />Criteria: <br />1 `5z— <br />z- <br />Comments - <br />on <br />1e' <br />made prior to testing, and recommended <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: ,� <br />Date: ,� <br />