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Ju 1. 30. 2015 6; 53AM No. 0519 P. 6 <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 />Facility Name: H & M KIWK SERV BW98 - ---Date of Testing; 7/29/15 <br />7/29/15 <br />Facility Address; 2501 E JACKSON ESCALON CA 95320 <br />Facility Contact: ALEX Phone, 209-838-3971 <br />Date Local Agency Was Notified of Testina: <br />Name of Local A <br />Company Name L.C.SERVICES <br />Technician Conducting Test: GaryHarris <br />Credentials: CICSLB Contractor 0 ICC Service Tech. <br />License N�Umbet(s): <br />FATINAH ZAREEF <br />0 S-WRCB Tank Tester 13 Other <br />%-om ments,- (include information on repairs made prior to testing, and recommended follow-up forfailed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all life h1formadon Contained In this report is true, accurate, and in full compliance with legal requirement& <br />Technician's Signature. — -I.- Date:- 7-45!-15 <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 />A <br />