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• r <br /> Afforda-Te$till Bucket <br /> 416 2nd Street 209 744-0112 Test Report <br /> Galt, Ca. 95632 FAX 209 744-0116 <br /> 1. FACILITY INFORMATION <br /> FacilityName: Date of Testing: <br /> Facility Address: 14 10 0 —r a 2 Q <br /> Facility Contact: Rlw -t Phone: — L? <br /> Date Local Agency Was Notified of Testing: lfza <br /> Name of Local Agency Inspector(ifresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: t'a. <br /> Technician Conducting Test: . t <br /> Credentials'; ❑CSLB Contractor C Service Tech. ffl.�B Tank Tester ❑Other S eci <br /> (P fy) <br /> License Number(s): 7 1 <br /> 3. S .L BUCKET.TESTING.INFORMATION <br /> Test Method Used: 99ydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Equipment Resolution: <br /> EME . illilill ,;III 11111111IM11111r, —1 <br /> Identify Spill Bucket(By Tank 1 ' A 2 .3 4 <br /> tc. <br /> Number,Stored Product, et� <br /> 14 Bucket Installation Type:° u'eet Buryc ury ury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in S ❑Contained in SaigT ❑Contained in Su <br /> Bucket Diameter: <br /> Bucket Depth: <br /> Wait time between applying 16 <br /> vacuum/water and start of test: <br /> Test Start Time(TO: <br /> Initial Reading(R): <br /> Mal <br /> Test End Time(TF): <br /> Final Reading(RF): <br /> Test Duration(TF—TO: <br /> Change in Reading(RF-RO: <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Comments.-(includeinformation on repairs made priorto ting, <br /> and recoinmende o ow-up for failed tests) <br /> ua <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information.co ined in,this report cs , `e accurate,and in.full compliance withlegal requirements. <br /> Date <br /> Technician's Signature: a: <br />