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0 <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 owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />r� <br />Facility Name: a e <br />Facility Address: !ry <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: /�. <br />Technician Conducting Test: <br />Credentials': Cf <br />Service Tec . SWRCB Tank Tester Other (Specif. <br />License Number(s): P <br />.. �.rwwr r ttw �!'vr�T mL•QTi1V(:' TNTi lli2MA'I'if)N 1 � � <br />Comments (include information on repairs made prior to testing, and recommenaea jouow-up)ur juclea --i <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained i� this report is true, accurate, and in full compliance with legal requirements. <br />s <br />Technician's <br />Date:_Ljd <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 />