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F F D ®1 E T 416 2nd Street Galt CA 95632 pilo Bucket <br />(209) 744-0112 (209) 744-0116 FAX��P o r <br />SITE NAME 0 — <br />ADDRESS <br />Q 20 <br />Inspector: <br />TEST DATE <br />PHONE( Z��j <br />Preser <br />Not Present <br />ros <br />Test Method Used:Hydatic ❑ Vacuum ❑ Other <br />Test Equipment Used: � p� zQ <br />G� <br />Equipment Resolution: � l_ (O " <br />Identify Spill Bucket (By Tank 1 2 <br />3 4 <br />Number, Stored Product, etc. es:. . <br />Bucket Installation Type: <br />Direct Bury <br />❑ Direct Bury <br />❑ Direct Bury ❑ Direct Bury <br />❑ ontained in S <br />❑ Contained in Sump <br />❑ Contained in S ❑ Contained in Sum <br />Bucket Diameter: <br />1 <br />Bucket Depth: <br />G Z <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (T): <br />Initial Reading (RD <br />I p 3 <br />Test End Time (TF): <br />t Z Z - <br />Final Reading (RF): <br />10-'3/4 <br />Test Duration (TF — TI): <br />Change in Reading (RF - Rj): <br />Pass/Fail Threshold or <br />_ <br />Criteria: <br />���a�� S If ��' i,u�II' ° YV MI `���p�'rrA : �qq ' <br />y <br />5Nd �•Y � J�� " Y'r� ����(( 1�, J <br />9�� 1Y1� 1)i yl 0 "nn I ! �[ ! 1 4 <br />/ <br />�IN I {•�. . <br />8ll ,.II„ � wn,, <br />­_ JUXaaac.aaw - (cnccuue inlurmauun un repairs maae prior to testing and recommended follow-up forfailed tests) <br />Test Water: _Taken with tester F� Left on site <br />I hereby certify that all the information contained in this report is true, <br />accurate, and in full compliance with legal requirements. Technician: , Zane A. NimrTlo <br />ts <br />ICC #: 5263322 -UT <br />Signature: - �� PTTt_ #: 04-1676 <br />