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1 <br />® <br />416 2nd 209 744 0Street 209 it A 95632 <br />( ) ( ) 4 0116 FAX <br />Spill Bucket <br />Test Report <br />❑ Other <br />Test Equipment Used: <br />TEST DATE <br />SITE NAME -Z1 <br />A' &J <br />PHONE( Zd,,9 <br />ADDRESS <br />2 <br />CONTACT: <br />d^ <br />I Direct Bury <br />❑ Contained in Sump <br />Direct Bury <br />❑ Contained in Sump <br />/� <br />Ins ector: 6x r e,�-- <br />p <br />❑ Direct Bury <br />❑ Contained in Su mp <br />Pres / Not Present <br />Test Method Used: <br />kHydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: <br />70 sTALtcl <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc)91 <br />i1 <br />2 <br />3 4 <br />L <br />Bucket Installation Type: <br />I Direct Bury <br />❑ Contained in Sump <br />Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Su mp <br />Bucket Diameter: <br />/ ► <br />/ r <br />>' <br />Bucket Depth: <br />I I <br />r <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TI): <br />Initial Reading (RI): <br />Test End Time (TF): <br />/vc? <br />jIU w <br />Final Reading (RF): <br />Test Duration (TF — Ti): <br />Change in Reading (RF - Rj): <br />All <br />Pass ail Threshold or <br />Criteria: <br />.Comments —(include information on repairs made prior to testing and recommended fallow -up for failed tests) <br />Test Water: , [Taken with tester ❑ Lefton s.K- <br />I hereby certify that all the information contained in this report is true,�a <br />accurate, and in full compliance with legal requirements. Technician;, Z ,*' 0 <br />ICC #: 5 s - <br />Signature: OTTL #: ®a <br />