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e � <br /> Afforda-TeSpill Bucket <br /> 416 2nd Street 209 744-0112 <br /> Galt, Ca. 95632 FAX 209 744-0116 est Report <br /> 1. FACILITY INFORMATION <br /> Facility Name: oy s ® l - Date of Testin <br /> FacilityAddress: fj ! r g' �� 9 <br /> Facility Contact: ) , Phone: <br /> Date Local Agency Was Notified of Testing: ? — z6---C)6 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: <br /> Credentials': O CSLB Contractor ❑ICC Service Tech. O SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: O Hydrostatic O Vacuum O Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number,Stored Product, etc. �2w <br /> Bucket Installation Type: irect Bury Bury ❑Direct Bury ❑Direct Bury <br /> Bucket DiaO Contained in S ❑Contained in S O Contained in S O Contained in Surnp <br /> meter: <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): u _ <br /> Initial Reading(RI): <br /> Test End Time(TF): <br /> Final Reading(RF): <br /> Test Duration(TF— <br /> Change in Reading(RF-RI): / <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Comments (include information 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 information contained in this report is true,accurate,and in full compliance with legal requirements <br /> Technician's Signature: Date: ( " <br />