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17-1 <br />0 - <br /># 1 9 , I I'l <br />Thisform is intendedfor use by, contractors performing periodic testing of USTsecondary Containment systems. Uselhe <br />appropriate Pages of thisform to report resultsfor all components tested. The completedform, written test procedures, and <br />prinioutsfrom tests (if applicable), should be provided to theja; ownerloperatorfor submittal to the local regulatory r. <br />i' <br />10 1. FACILITY INFORMATION <br />VIM Date nf Te-zh.p" A <br />Facility Ad !T!!. <br />Co <br />a c <br />Locai <br />Name of Loca <br />2. STING CONTRACTOR INFORMATION <br />CornpanX Name: <br />;Technician Conducting Test: .2 <br />1 Credentials- 1A CSLB Licensed Conft-dctor El SWRCB Licensed Tank Tester <br />License Number <br />Manufacturer Traiging <br />Manufacturer co <br />Date Training Expires I <br />la. I <br />MTM, <br />Component <br />Pam <br />Fail <br />=Not— <br />Tested <br />Rep—airs <br />Made Component <br />Pass <br />T� <br />in <br />Made <br />El <br />f] <br />o <br />11 <br />El 1] <br />11 <br />U <br />0 <br />EJ <br />D <br />El <br />El <br />❑0 <br />U <br />11 <br />U <br />El <br />0 <br />n <br />Ll <br />El El <br />[I <br />--11 <br />[1 <br />H <br />0 <br />0 <br />0 B <br />El <br />0 <br />F1 <br />F1 <br />EJ <br />1j <br />11 Cl <br />0 <br />0 <br />Ll <br />U <br />IJ H <br />El <br />❑ <br />1i <br />Ll <br />1.1 <br />El <br />0 0 <br />n <br />❑ <br />H <br />11 <br />0 <br />[J <br />Ll [1 <br />0 <br />El <br />U <br />El <br />F1 <br />11 <br />El ElF-1 <br />Li <br />Ll <br />tj <br />L1 <br />11 <br />1 1 <br />If <br />it testin&,was&"b jT1 <br />�Mj 0'W�461 <br />CERTIFICATION OF TECHNICIAN RESPONSHILE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, th faM stated hr this doeunwnt are accurate and inful! compliance with legal requirements <br />Technician's Signature: Date: <br />