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SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is tntendeel for use by eonrractorr performing anmial tasting of US7'spill containment structures. The completed form and <br />printouts from rcatc (if applicohle), should be provided to the facility owner/operator fvr submittal to the local regulatory agenev. <br />1. FACJLM— JNir'ORMATION <br />Facili Name' ' �} <br />'Facility Address: <br />Facility Contact: <br />Date Local Agency Was Notified of Testing: <br />Name of Ucal Agency Inspector (cf present durinz tkstinz): <br />Coni as Name; U,S.T. Compliance Testing Inc. <br />Technician Conducting Test; Tony Fontana <br />Credentials'; x CSLB Contractor x ICC Service Tech, <br />License Number(s): 846288 1064273 -UT <br />3. CPTT.T. <br />Date of <br />rUORMATION <br />0 SWKCD 'tank Toster ❑ Other <br />INFORMATION <br />CERTIFICATION the <br />pF TEC>F[NlCIAN RESPONSIBLE FOR CONAUCTiNC T.IIIS TESTING <br />thereby certify [hut all the lA,formu trained in 1h <br />%° �4 true, accuQUe, and it fkll complia[tcc with legal requirements. <br />Technician's Signal <br />' Stato laws and regulations do not currently require testing to bo Perforumed by a qualified contractor, l40wevcr, local re u <br />may be more stringent, <br />q trcments <br />SfS'd 22t7289b:01 96LTT2S602 3DNHI1dW09 1S():WOdA LS:LO t7T02-t72-),HW <br />