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+ wL <br /> • <br /> Thisfor17MINN <br /> 1i* dart containment �'es <br /> appropriate fforusebycontractorspeYor tlnb �@ OPt 0P <br /> printouts r Pages° this form to re f min F in Pages of <br /> /otn tests i Port results for all9Periodic testing° U <br /> rf aPDlrC°bleJ, should be COr"p�c�s tested f STsecpleted contatm»ent sJ stems the <br /> provided to the d Thec°nJ°nda <br /> Facility Name: 1• FACILITY tYownerloperatorforsubmitaltuenteslprocedurehe <br /> Facility Address.. �"ry IlVFOR1yUMN to the local regulatoand <br /> Facility Contact: 'Y agency• <br /> Date Local rp °� Le S ata �� Date of Testing. <br /> Agency Was Notified of T <br /> NameofLocalAgenc _fig' tf 4 a <br /> —07- 0 - Phone: <br /> Y Inspector/ifprexent during testrng): /000 <br /> CLV <br /> om any Name: 2• TESTING'CO <br /> Technician Co �'r of a_ NT12ACTOR <br /> nducting Test: T� a r FOE TjoN: <br /> Credentials: <br /> License T ❑CS LB Licensed Contractor <br /> s,,.ype; <br /> CB Licensed Tank Tester <br /> Manufacturer License,NUwn ber _ <br /> Manufacturer Trainin g� //y3 <br /> Com onent s <br /> Date TraininE Ex fres <br /> Component 3 S""ur eY OF TEST RESTJLTS <br /> Pass Fail Not Repairs <br /> Tested Made <br /> Component <br /> ,X Pass Fail Not Repairs <br /> t , X Tested Made <br /> ❑ <br /> ❑ ❑ ❑ <br /> ❑ 0 ❑ 0 <br /> ❑ 0 ❑ 0 <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ 0 ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ p ❑ 0 <br /> 0 0 ❑ ❑ <br /> astatic testing was Performe des ❑ ❑ ❑ <br /> � � cn'be what was done ❑ El ❑ <br /> '° t— /prn r� with [he water ager completion of tests. ❑ ❑ <br /> S> sG> <br /> CERTIFICATION OF <br /> TECHNIC <br /> •t°fmY knowledge,the facts IAN 1tESPONSIB <br /> stated• <br /> 1hLr docunteni are accurLE FOR Cate an ONDf ll co ING THIS TESTING <br /> S Signature: _,f. j/ mpliance with Legal requirements <br /> Date: <br />