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A Spill <br />416 2nd Street 9 i <br />Galt, Ca. 95632 FAX 209744-0116 —0 1 Test Report I <br />1 IRA rTT .TTV YMMD Xr A rrasnxT <br />FacilityName: ()0JU- loo <br />Date of Testing: 5-t,pj <br />Facility Address:1 t - l <br />Facility Contact: htta,� I Phone: - i l <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (if present during testing): <br />2- TF.RTTNC- r('bNTR A rTnR TArnnrX A 'rrnlr <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the in ma ion con .ned in. this report is true, accurate, and in full compliance wit lega . requirements. <br />Technician's Signa <br />4 <br />Date: <br />f <br />Company Name: 1 O --- ----- - <br />Test Method Used: <br />Technician Conducting Test: <br />❑ Vacuum <br />Credentials l: ❑ CSLB Contractor ❑ ICC Service Tech. )VSWRCB Tank Tester ❑ Other (Spec) <br />Test Equipment Used: <br />License Number(s): L4 1(21(0 <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the in ma ion con .ned in. this report is true, accurate, and in full compliance wit lega . requirements. <br />Technician's Signa <br />4 <br />Date: <br />f <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: <br />"° <br />j` � <br />Equipment Resolution: s 1 <br />Identify Spill Bucket (By Tank <br />1 --' <br />2 <br />3 <br />4 <br />Number, Stored Product, etc. <br />Bucket Installation Type: <br />9Direct Bury <br />9 Direct Bury <br />ff Direct Bury <br />❑ Direct Bury <br />❑ Contained in Sump <br />0 Contained in Sump <br />0 Contained in Sump <br />0 Contained in Sump <br />Bucket Diameter: <br />Bucket Depth: <br />t <br />1. <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Tj): <br />Initial Reading (Rj): <br />Test End Time (TF): <br />Final Reading (RF): <br />% <br />4 <br />Test Duration (TF — TI): <br />Change in Reading (RF - RI): <br />Pass/Fail Threshold or <br />Criteria: <br />REM <br />Comments - (include informa bn on repairs'made prior to testing and recommended follow-up for failed tests) [ <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the in ma ion con .ned in. this report is true, accurate, and in full compliance wit lega . requirements. <br />Technician's Signa <br />4 <br />Date: <br />f <br />