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rAfforda-Te$t <br />416 2nd Street <br />Galt. Ca. 95632 <br />Name:( <br />Address: <br />Contact: <br />C <br />209 744-0112 <br />FAX 209 744-0116 <br />I,- FACILITY INFORMATION <br />I Date of Testing: <br />6*0 rkto w <br />, <br />Phone: 2-Cq gyp, - <br />Date .,Local Agency Was Notified of Testing: <br />Mattie of Local Agency Inspector (ifim-esew during testing): <br />to <br />2. TESTING CONTRACTORINFORMATION. <br />Company Name: <br />Technician Conducting Test: Z t. r )I <br />Credentials 0 CSLB Contractor NCC Service Tech. NSW CB. Tank Tester 0 Other <br />License Number(s): <br />ri <br />--! (inctuae information on repairs made prior to testing, an <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS S TESTING <br />hfr0by. certify that all the information contained in this report is true, accurate, and in full compliance Awmithrile legal Irements, <br />gal, quireinents. <br />Technician's Signa <br />tU4 Date: <br />...................... <br />3. SPILL BUCKET. TESTING INFORMATION <br />Teg!Mdthod Used: <br />Hydrostatic <br />0 Vacuum <br />0 Other <br />k4qq!pment Used: -T�.PF <br />I C) <br />Equipment Resolution: 1 <br />Idelitify Spill Bucket (By Tank <br />M <br />umber, Stored Product, etc. <br />1 <br />2 <br />11 <br />\j L L <br />- 111111 <br />.3 <br />4 <br />6u 1c) <br />Bucket Installation Type: <br />0 Direct Bary <br />®Direct Bury <br />0 Direct 13ury <br />0 Direct Bury <br />11 Contained in Surtip <br />0 Contained in Sum <br />-P <br />0 Containe4jE§2!M- <br />Bucket Bucket Diameter: <br />Bucket Depth: <br />1 L4 <br />,,,.,Wait time between applying <br />2- <br />�Iji and start of test: <br />Mi---------- <br />,K$&ft Time (TO: <br />o <br />IMM Nading (Rj): <br />3 ILI <br />—LQLQ—C:L— <br />Test End Time (TF): <br />41 al <br />0 1 A - <br />Final Reading (RF): <br />Test Duration (TF - Tj): <br />Change in Reading (P F - RI):„ <br />;P- dp ilThresholdor <br />Ttgvp <br />--! (inctuae information on repairs made prior to testing, an <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS S TESTING <br />hfr0by. certify that all the information contained in this report is true, accurate, and in full compliance Awmithrile legal Irements, <br />gal, quireinents. <br />Technician's Signa <br />tU4 Date: <br />...................... <br />