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Spill Bucket <br />416 2nd Street 209744-0112 <br />Galt, Ca. 95632 FAX 09 744-0116 Test Report <br />1. FACILITY INFORMATION <br />Facility Name: QD0j Date of <br />Facility Address: 'b32 S S 5tDCkC <br />Facility Contact: O V1 I Phone: <br />Date Local Agency Was Notified of Testing : d q 10 7 <br />Name of Local Agency Inspector (ifpresent during testing): <br />2.. TESTING CONTRACTOR INFORMATION <br />Company Name: 777V1 <br />Technician Conducting Test: Lie, Nt ro o -) (,) <br />Credentials 1: ❑ CSLB Contracto E(ICC Service Tech. XSWRCB Tank Tester ❑ Other <br />License Num er(s): <br />3. SPHJ. RTi(`KFi.T TFCTTNr nvcnniL& A T4!\,AT <br />0 <br />vii re arts mase trot zo testang, and recommended follow -u for failed tests) <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 />k <br />Technician's Signature: " <br />Date:I, <br />