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r r� <br />SWRCB, January 2002 <br />0 Page _1_ of_6_ <br />11 1i LIfI ` i' x'11 i II <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of this form to report results for all components tested The completed form, written test procedures, and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />A rem K13 13 reic MI <br />.e r.,r.. cYmrwrly -.iwWrr'n" a !'rTl1D i-&TT/11DAif A T1f11N <br />ENVI M,,'IF':� l HLEALTH <br />I►l �\1 1 : . <br />Component <br />MM <br />Component <br />DIESEL ANNULAR <br />VENTSECONDARY= <br />0000 <br />0000 <br />�• , <br />= o00 <br />0000; <br />� <br />-o00 <br />ooi000 <br />= o00 <br />000000 <br />0000 <br />0000 <br />0000 <br />ooMM <br />0000:: <br />oo�oc000 <br />000■� <br />0000 <br />oi000 <br />oi0000� <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />All Test Water was re -contained in (2) SS gallon poly drums and (1) 30 gallon drum. All drums are <br />labeled as Non -Hoz and are ready for transport. No water was removed from site. <br />CERTIFICATION OF TEC CLAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stv7FIS cr, curate and in full compliance with legal requirements <br />Technician's Signature: Date: -1/9/06 <br />