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0 <br />Spill Bucket <br />416 2nd Street 209 744-0112 1; <br />..st Report <br />Galt, Ca. 95632 FAX 209 744-0116 <br />1. FACILITY INFORMATION <br />Facility Name: 5j Date of Testing: -, j - <br />Facility Address: StM2k <br />Facility Contact: �. e A Phone: 1} <br />Date Local Agency Was Notified of Testing: -2 - /87_ 0 <- <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: 4��- O IZI) E : � _T-". P <br />Technician Conducting Test: Ly � ) 0 <br />Credentials': 0 CSLB Contractor SCC Service Tech.-5kSWRCB Tank Tester ❑ Other <br />License Number(s): <br />3. SPILL BUCKET TEST iNCa TNMUMA7-Miv <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in. thiss report is true, accurate, and in. full compliance with. legal requirements <br />Technician's Signature: Date: --2 <br />