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Oct -14 11 10:01a Elite IV Contactors 12094616342 p.2 <br />SWRCB, January 2006 <br />Spill Bucket Testing Report F(. l,a <br />This farm is intended for use by contractors performing annual testing of UST spill'con tc ment structures_ The completed form and <br />printouts fro»i tests (f applicable), should beproWded to.thefacility ownerloperator fc;r bmittal to the local regulatory agenry. <br />1...,:F.:CTLITY:INFORMATION. _ <br />of Testing: <br />Facility Name: -I a— " <br />Facility Address: 57-r6 t — <br />�.. _ X Phone: '`%i-Cic'b <br />7 - <br />Facility Contact: — <br />Date Local Agency W Notified of Testing.: l <br />Name. of Local Agency Inspector (f present during tesiin�: _ <br />2. TESTING CONTRACTOR INFORMATIOI'—Z <br />Company Name: <br />Technician Conducting Test: <br />(Specify)Credentials': 0 CSLB Contractor eryice Tech. ❑ SWRCB Tank Teste►_ O Other (Specify) . <br />License Numberks) > (�{`j1� . 81��� Q . {k.2 <br />& SPILL. BUCKET. STING.INFORMATJ <br />TE(_C it <br />0 C ,er <br />E,ment Kesolunon: <br />... r _ <br />.7�• — <br />1 ft Criteria: - <br />tl 1 <br />CERTInCA'I'iON OF TECHNICIAN RESPONSIBLE FOR CU1!f D 3C"ula c Tffi TING al requirements, <br />I k'ereby certify that all the. information: contained in. this report is. true, accurate, a n in full comp 'ance with. gq <br />Technician's Signatuie. <br />be performed by a quali: it l contractor. However, local requirements <br />t State laws and regulations do not currently require testing to <br />maybe snore stringent. _....._.._ _ ....... . <br />