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r <br /> A Afforda-Te$tit <br /> 416 2nd Street 209 744-0112 est Report <br /> Galt, Ca. 95632 FAX 209 744-0116 <br /> 1.. FACILITY INFORMATION <br /> Facility Name: � .� ,Q Date of Testing: <br /> Facility Address: -303k�c. �,r- � <br /> t i) <br /> Facility Contact: q I Phone: '�-p <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: a, <br /> Technician Conducting Test: o <br /> Le a eiw <br /> Credentials': ❑CSLB Contractor CC Service Tech. CB Tank Tester ❑Other(Spec) <br /> License Number(s): ! <br /> 3. SPILL BUCKET.TESTING INFORMATION <br /> Test Method Used: ydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: j V 0 Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number,Stored Product, etc. e�°� It <br /> irect B Bury ❑Direct Bury <br /> Bucket Installation Type: Bury uect Bury uect B <br /> ❑Contained in S ❑Contained in S ❑Contained in Su ❑Contained in S <br /> ump <br /> R Bucket Diameter: 'r <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: " <br /> Test Start Time(T): © 3C>q3 <br /> Initial Reading(RO: <br /> Test End Time(TF): <br /> Final Reading(RF): <br /> Test Duration(TF—TI): t r-"- <br /> Change in Reading(RF-Rj): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Comments.-(include information on repairs made prior to testing, 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 /> Technician's Signature:. - ....... <br /> .., °°;�' Date: <br />