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Oct i9 10 12:09p Elite IV Contactors 12094616342 <br />p.6 <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />tesThis form is intended for use by contractors performing antheafacilinnowne operator forcontainmentTspill submittastructures. the local regulatory agency - <br />and <br />printouts front tests (if applicable), should be provided to 11' <br />1. FACILITY .INFORMATION <br />Date of Testing: <br />Facili-74 <br />ty- <br />Facility <br />Facility Contact: <br />Date Local Agency Was Notified of Testing : x <br />I,Tarne of Local Agency Inspector (if present during <br />2. TESTING CONTRACTOR INFORMATION <br />71 <br />Company Name: 7>7.= <br />Technician Conducting Test: a .r ^ " <br />Credentials`: O CSLB Contractor g,ICC Service Tech. D SWRCB Tank Tester ❑ Other <br />License Number(s): <br />3. SPILL. BUCKET. TESTING INFORMATION <br />Comments — <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that alt the information contained in. this report is true, accurate, and in. full compliance withlegal requirements. <br />/ — Date: <br />Technician's Signature: <br />State laws and regulations do not currently require testing, to be performed by a qualified contractor. However, local requirements <br />may be mole stringent. <br />