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Afforda-Te$t Spill Bucket <br />416 2nd Street 209 744-0112 <br />1; Test Report <br />Galt, Ca. 95632 FAX 209 744-0116 <br />1_ FAfTT.TTV TNF()RMAT1rnV <br />FacilityName: - Date of Testing: �j -- .. <br />0 6 <br />Facility Address: r r , <br />Facility Contact: jai e�n r z d Phone: 9 - <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (if present during testinL:, <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: �- 5 <br />Technician Conducting Test: e V, <br />Credentials': ❑ CSLB Contractor CHr.Y' Service Tech. CB Tank Tester ❑ Other (Spec) <br />License Number(s): _6_.9- a 7' 4 --) ®/y --;; <br />Test Method Used: <br />Test Equipment Used: <br />Identify Spill Bucket (By Tank 1 <br />Number, Stored Product, etc. <br />Bucket Installation Type: <br />Bucket Diameter: <br />static <br />0 Vacuum <br />❑ Other <br />Initial Reading (RO: <br />Equipment Resolution: <br />Test End Time (TF):�I , <br />2 < <br />3 <br />4 <br />Bury <br />uect Buryirect <br />Bury <br />0 Direct Bury <br />tied in Sump <br />❑ Contained in Sump <br />❑ Contained in Sump <br />❑ Contained in <br />;z_ <br />/ "71 <br />1-2 <br />Wait time between applying <br />vam/water and start of test: <br />Test Start Time (TO: <br />ODD tv <br />Initial Reading (RO: <br />Test End Time (TF):�I , <br />Final Reading (R)' ` � __ . _.,_._.,. 9 - <br />Test D /T <br />Change in Reading (RF -RI): <br />Pass/Fail Threshold or Ae r. <br />Criteria: <br />Comments. - <br />on repairs made prior to testing; and <br />CERTIFICATION OF TECMNICIAN 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 />d <br />Technician's Signature: �f ., Date:7_)-,;1-Q <br />