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4 <br />11 <br />01 130620-293 <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br />printouts from tests (if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Faciliq Name: Manteca co Date of Testing: 8/6/13 <br />Facility Address: 430 W. Center Street <br />Facility Contact: Vincent Scheaffer Phone: 209-401-4547 <br />Date Local Agenc <br />I Was Notified of Testing: 48 Hours Prior <br />Name of Local Agency !n!2ector ffresent !Lu�n testiS: Elena Monza <br />2. TESTING CONTRACTOR INFORMATION <br />3. SPILL BUCKET TESTING INFORMATION <br />. Comments - (include information on repairs made prior to testing, and recommended follow-up 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 requiremmis. <br />NbIly soed byPaul Kane fu 01362M <br />Technician's Signature: W01311:49:29 Date: 8/6/2013 <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />