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Oct 17 12 08r36a Elite IV Contactors <br />B+ r s <br />12094616342 p.5 <br />9 <br />SWRCg, January 2006 <br />t <br />Spill Bucket Testing Report pori m <br />This form is intended for use by contractors perfondng annual testing of UST spill carte "men' structures. The coinpdeted forra and <br />printouts from tests Cf applicable), should be provided to the facay owner/operator jr, r tibmittad to the local regulatory agency <br />1. FA . iNFQ TION. *-,-h . <br />Facility Name: <br />Facility Address: ` <br />Facility Contact �! ` <br />Date Local Agency Was NOt-tfied OfTesft- <br />Na= of Local Agency Inspector (rf present d <br />2.. TESTI NI <br />COmpy Name: <br />Teciwician Conducting Test: <br />cmcienzfa&I: O CSLB_Contractor " � ICC <br />License l�iumber{s): �t i7 � 'N; Pi! <br />3. SPILL <br />Test Method Used:. stat <br />Test Ea QiDMCnt Used <br />ving testing): <br />CONTRACTOR INFOTIO:! <br />Service Tech. 0 SWRCB Tank Testa- Q Other (Specify) <br />gUCK ,T. TESTING INFO TI';( °i. -- <br />c 0 Vacman [I C lxer <br />Eq+ Sa nt esolution: <br />made prior to <br />r f M�: r <br />n rr :■ x 4 <br />� Fwr tea.. ... <br />r <br />CERTIFICATION OF IMC NICL4N RESPONSIBLE FOR CONI d.:TIN+G TESTiNCx. ' <br />I hereby that all ilia in matian contain ort rr , nt i'ra. fun comp ' with legal req ' enm <br />Date• <br />Teclnciatt'S Signature: <br />x State laws and rc Mations not currently require testing to be performed by a qualif.e- contractor. However, local -req <br />s rr <br />■.: ♦x✓ r -t tx :xtaf <br />r rr. <br />■ rrr,x+:-t t tit♦ <br />txx r f. a <br />xe' � <br />r t rr+ <br />made prior to <br />r f M�: r <br />n rr :■ x 4 <br />� Fwr tea.. ... <br />r <br />CERTIFICATION OF IMC NICL4N RESPONSIBLE FOR CONI d.:TIN+G TESTiNCx. ' <br />I hereby that all ilia in matian contain ort rr , nt i'ra. fun comp ' with legal req ' enm <br />Date• <br />Teclnciatt'S Signature: <br />x State laws and rc Mations not currently require testing to be performed by a qualif.e- contractor. However, local -req <br />