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Spifl Bucket Testing Report Form <br />7hisform is intendedfor use by contractors pefformin <br />y, annual <br />tri =-*1PZY,77/707Ma?e proviaea to me./acility own <br />1. ] <br />Facility Name: ECONOGAS —� <br />Facility Address: 880 E. VICTOR I <br />Facility Contact: IWANVIk— <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (f present c <br />I P V L-jsflf . �i�# � <br />................. <br />........... <br />W 0 �00 <br />teslb�o: ARIS CACAPIT <br />--9 2. TESTING CONTRAcToR mogmAToN <br />Company Name: BZ Service Station Maintenance <br />Technician Conducting Test: JE R kM—Y— C— U—M—M—INS <br />Credentials': <br />NSCredentials': X CSLB Contractor X ICC Service Tech. 0 SWRCBT ank Tester 0 Other <br />License Number(s): 433159 <br />I QPYt I UTWIXFVT Ism Cmpw*.T/'V <br />Hm <br />maae prior to testin-e, and <br />''I low1111111111; <br />I100 IMM -011,1111 <br />CER CATION OF TECL4,N NS LE FOR CONDUCTING THIS TESTING <br />Ikereby certify that all the in rinadon contained In this report h lrue, accnram4 and injkff compliffnce with legal requiremeniX <br />Technician's Signature: 7F7 Date: 12-01-10 <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 />