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SVWRCB, January 2002 Page of <br />Secondary I ., tno <br />��` t 1 1 <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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />I- FACILTTY INFORMATION <br />2. TESTING'CONTRACTORINFORAIATION-'* <br />Uom an Name: <br />Technician Conducting Conducting Test:_, <br />Credentials: ❑ CSLB Licensed &ntractor B Licensed Tank Tester <br />License Type:. License Number: 2-- <br />Manufacturer Training <br />Manufacturer -Component(s)Date Training Expires . <br />O <br />component <br />Component <br />: <br />mom= <br />on <br />no <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: <br />.� � Date: /<�� _/ iD' <br />