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SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />7fhie form is intended for use by contractors performing anneal testing of USTspill containment structures. rhe completer! form and <br />printouts from tests (if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br />1. FACILIT'9C M ORMATION <br />i-•,acility Name: H & M KIWK SERV BW98 - Date of Testing; 7/29/15 <br />Facility Address: 2501 B JACKSON ESCALON CA 95320 <br />Facility Contact: ALEX Phone: 249-838-3971 <br />Date Local Agency Was Notified of Testing. <br />Name of Local Agency inspector (rf present during testing) FATINAiH ZAREEF <br />TESTING CONTRACTOR INFORMATION <br />Company Name L.C.SERVICES <br />Technician Conducting Test: GaryHanis <br />Credentials: O CSL$ Contractor D ICC Service Tech. p SWRCB Tank Tester Q Other <br />License Number(s): <br />a..uuewe"is — onctucte tnjormation on repairs made prior to testing, anti recommendedfollow-upfor fafled (ests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby cetYlfy that all the Information contained In oils report is trite, accurate, and laf ell coniplimtee Willi legal regturemews <br />! Technician's Signature: Date: -� <br />5 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 />