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Jan 310 12 12:17p Elite IV Contactors 12094616342 <br />p.3 <br />__1_ �:D— <br />SWRCB, January 2006 <br />This form is intended for use by contractors performing annual testing of UST spill ca; tc nment structures. The completed form and <br />printouts from tests (if applicable), should be provided to thefacility owner/operatorf: r ubmittal to the local regulatory agency. <br />IRA r'rr TTv TIVRORMATTON <br />Facility Na e: 1 L a <br />Facility Address:S `� �(! <br />Facility Contact Phone:ZX <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <br />Spill Bucket Testing Report F+:►1 1n <br />2. <br />Canspany Name- �J--e <br />Technician Conducting <br />Test: l <br />Credentials': 0 CSLB Contracts <br />License Number(s): <br />s <br />TESTING <br />COI�ITRACTOR IlYFORMATIOIt.._ <br />Contractor 0 ICC Service ech. 0 SWRCB Tank Teste:t– 0 Other (Specify) <br />Z carr .T , RTJCKET TESTING I.NNFORMATI.O N <br />� <br />comments -- (include information on repairs made prior to testing, and recommenr,'e, <br />;`ollow-up for failed tests). <br />CERTIFICATION OF TECHt`rICIAN RESPONSIBLE FOR COhrE?1 (;TING TffiS TESTING <br />1 hereby certify that all the information. contained in: this u report true,. accurate,. a?i4 's,2 full compliance with. legal requirements.. <br />DaterTechnician's Signature: <br />r State laws and regulations do not currently require testing to be performed by a quaiifi:a contractor. However, local requirements <br />tnay be more stringent. . <br />