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Aug .31 09 09:00a Elite IV Contactors 120946 6342 p.6 <br />SWRCB, January 2006 <br />Spill Bucket TestingReport Form <br />T7sis form is intendedfor use by contractors performing annual testing of UST spill containment structures. Tne completed form and• <br />printouts from tests (if appPicable), shoulit be provided to the facility owner/operator for submittal to the local regulatory agency,. <br />..1. ,:: FACILITY: INFORMATION <br />Pddress: <br />ame:�ZyC <br />s Date of Testing: <br />L (� l3'��� <br />ontactPhone: <br />l Agenfied of Testing.: <br />Name. of Local Agency inspector (if present during testing): a <br />2.. TESTLNG CONTRACTOR INFORMATION. <br />Company Name: 4 4 u� <br />Tecbnician Conducting Test: _PiZf� <br />Credentials': D CSLB Contractor -ICC Setvice.Tech. 0 SWRCB Tank Tester 0 Other (Specify) <br />. .License Number{s): • <br />COri2II1eIItS. = rinclude informafton on repairs ma"t; Priu, 1-v <br />CERTIFICATION OF CEINICIAN RESPONSIBLB FOR CONDUCTING TSFS TESTING <br />X hereby certify that a1L the. inform n: contained in: this. report is. true, accurate, and in. fkll compliance with, legal requirements.. <br />Technician.'s. Signature• Date:, <br />I State laws and regrilatia t currently require testing to be performed by a qualified contractor. However, local requsremeats <br />may be more stdngent. . <br />