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140808-186 <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 ownerloperatorfor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />2. TESTING CONTRACTOR INFORMATION <br />Comments - (include information on revairs made prior to testinz, and recommended follow-up -for-failed tests) <br />E vinnhW <br />ENTAL <br />HFAI r#4r1FP4P'r4A T <br />CERTIFICATION OF TECHN[CL4N RESPONSEBLE FOR CONDUCTING TEUS TEST I Q <br />I hereby cerWfy that all the Information contained In thisrtistru accurate, and infull compliance with kgal requirements. <br />DoallysoO byPaul KanerorT#140N " <br />Technician!s Signature: 51131410:41:46 Date: 9/11120114 <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 />Document Reviewed 9/12/20149:15 AMJustin Trelstad <br />