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F RECEIVED 04/22/201 1:04 <br /> Apr �2 1.4 07:58a Elite Contactors 12094914 � 2 <br /> S%°RCS,jwdary 2006 <br /> Spit u+eet' g e ,�c <br /> 77&form is amended for.use by con"Liars perfomaidg annual°evtang of UST spill e c n eirar�aerats . rer. Tae as Iste o and <br /> pa ar�touts from tests(if4ph67b1eJ;shauld bepmvided to the facifity Ownerigperator•,�o submittal to the local regulartory agency. <br /> 1. FA ID . TIONI <br /> ?aGlity Nam: ?. a e 1 esng: <br /> FacMty Address: <br /> Facility CDntact Pho <br /> _. <br /> `date~Local2Lgecy Vas Notitaed of Testing: C <br /> +tamp of IAZ Agency or f prses:ent.dwing'lcsdngh. <br /> I ITS nNG CONTRACTOR RMRMATIO,.4 <br /> `Teef�cfim Chm&wting Test: <br /> bale': ri.csm t:ontraofor CC Service Tech. CBT Te e_ 0Od=(Sp f)1 <br /> 3. . T O d: <br /> _YeWMedii6d Used: , H astatic' l7ita 0'� ?' - <br /> Used:` Ecu t `o= " <br /> IdexY'Sps�i Bucket(By'TanTt 1 .2 3 4 <br /> ter. eda eta :1.' <br /> tion <br /> Direct <br /> Bury. LID C113i ret 8 t7 Dh=t Bwy <br /> p inS ❑ din Cl tit .i i� 4 0 nt in'S . <br /> BjcW DeF h <br /> W=7t_d=between applying <br /> 'vicumAnter and stwoftest. <br /> Tot Start Time <br /> -- <br /> _._. Initial Roading OQ: <br /> Test End Ts .(TF): <br /> Final Rea (RF). LL <br /> Omke is Rem ding(R4-R4): pJ0 _ <br /> Threshold or <br /> G�'4�rffi;11iCrif5®(include +rdeLnor°to A r- al al Pio , up fogBXlle t <br /> i'.i a lLhW.Dtx-zrAP�pc� S t h f!a g ..± <br /> z <br /> TIFICATI®NOF. NS LF, CO Usk t STNG <br /> X certify that alI the irtfP rr'coidirwed AA Mk report Prue, c r arsd..i M. camp. ae -� <br /> T <br /> _.,_• . .. ..g. .-laws- ham=da•�ot' �y • <br /> may be WOM stringent <br />