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5 OR 10 YEAR INSPECTION <br /> Date and Year tank was initially lined <br /> This inspection is within 10 years of lining Yes No or is a 5 year thereafter inspection <br /> Yes No <br /> TIGHTNESS TEST CERTIFICATION <br /> I, the undersigned,hereby swear and attest that I have performed a precision test in accordance with <br /> NLPA Standard 631, Chapter A, Section 12.1.3 and A13.2.3 on the above designated tank system <br /> and certify that the tank was "tight" and in compliance with 40 CFR 280.33(d)(2) and that the tank <br /> passed the precision tightness test in accordance with NLPA Standard 631,Chapter A: <br /> Signed Date <br /> SPECIAL INSPECTORS OR <br /> QUALIFIED PERSONS SIGNATURE <br /> I have not performed a precision test in accordance with Chapter A of NLPA 631: <br /> Signed Date <br /> SPECIAL INSPECTORS OR <br /> QUALIFIED PERSONS SIGNATURE <br /> Page 2 of 3 <br /> 57 <br />