Laserfiche WebLink
Sep 19 02 08:24a Elit Contractors Inc 20946163 p.4 <br />SWRCB, Tanuary 2006 <br />Testing Report Form <br />This form is intended for use by contrpctors performing annual testing of UST spill containment structures. The completed form and <br />priwouisfrom tests (fapplicable), should be provided to thefacility ownerloperatorforsubmittal to the local regulatory agency. <br />I- 1 ACTI.TT'YiNFt)RMATFON <br />Facility Name: 11.+9 M4:t iv A4Date of Testing: ti -11-09 <br />Fadlity Address: l rvty� y-�e <br />FacilityContact T' t Phone: iC 9 - C`Xrt i <br />Date Local Agency Was Notified of Testing : - G`(; (� 4 C_l' C - I -C) (�n <:A: a <br />Name of Local Agency inspector (ifpresent during testing): o <br />2_ TF..CITNC C'.flN7'RAf'T(11l' iNiitlRA/fATi(lTi <br />Ca y Name: M <br />Tecianician Conducting Test <br />Credentials: 0 CSL.B Contractor ICC Service Tech 0 SWRCB Tank Tester . 0 Other ec.fy 1CI <br />.T,icenseNamber(s):,_l �' ') C)T <br />CERTIFICATION OF TE CLAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />1 hereby certify. th0 all the informad ne. contained. in. this report is tru4 accurate, and in full compliance sixth,!eget'. requirements.. <br />Technician's Signator �'- -' Date — <br />State laws and regulations do not currently require testing to be perforrued by a qualified crnntraetor. However, local req<iiremenis <br />may be more stringent <br />