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Jul 06 10 11:06a Elite IV Contactors 12094616342 p.5 <br />Mab 18 08 12:54p Elio Iv Contractors Inc 2054616 j — 77— <br />SwX0, Juno -W 2006 <br />Spill Bucket Testing Report Form <br />174vfbmi Is insmiled for use by confrqc1orsparforwingannual 1,jig of UST spill conrainmeAt s1ruc*res. The complem armand <br />p-j,rzjojjjw from tests (if applicable). should he proWded to adic,,faciii(yomierjoperatorforsubm.litalloJhCIVCa!regulat*rYOgcncY- <br />1. FACILITYINFORMATION - 0 <br />FacXtYN2vw: Date of Tc%d <br />Facility Address: '7L C 5 1 01!h <br />Facility Contact <br />Date Lova! A9=cY Was Notified of Testing.: <br />Name of Local Agency Inspector r1fpment during testing): <br />Z. TESTING CONTRACTOR KWOMATION. <br />-:Fc–ch–wic—ian Conducting Test 0; <br />Cradentiah': OCSLBC=tr-dctor 'gICC Somice"Tech. 0SWRC33Tank Tester D0der(SPedfY)....,.,,-,.- <br />- <br />License N.UdDer(a). <br />Von <br />a <br />mr. FTj <br />7iff, <br />�7 <br />Conments— Include Mum&zbn on repairs made prior zo fe.Ong. OW <br />CMMICATION OF TWUNICIM RES 'SMLE FOR CONDUCMG TMS 'TESTING <br />jk,,reb.r =d& dug all the. information. .eon &4*%f;,( this report LT trace, accar"C'. andira full Compliance Wd,( k9fif requirements.. <br />61 Techoid"'s Sipaimc Date. <br />Site jaw and regiWations do not ==tly vcquim testuig to be perfowwd ay a quanshd contractor. Howcvcr, local-req&ewents <br />may be mom swidgent <br />