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RECEIVED <br />NV VffM3anuary 2006 <br />O <br />Spi'll Bucket Testing Report Form <br />ThisArm islintended for use by contractors performing annual testing qJ11STspill containment <br />NM rM and <br />I t <br />Fran, tests (if applicable), should be provided to the facility owner/operatorforsubmitt, t rei* <br />Printoutsf 'u aton <br />re atoty agency. <br />FACLLffy INFORMATION <br />Facility Name: H &M KWIK SERV I -- - of Testing: 8-9-13 <br />Facility Address: 2501 E. J i�s—&1-- <br />Facility Contact: HASSAN Phone: (209) 838-3971 <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained In this report is true, accurate, and infull compliance with legal require ment& <br />Technician's Signature:_ Date: 8-9-13 <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 />