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California i Containment t• Sport Form <br />This form is for use by contractors performing periodic testing of UST secondary containment systems. The completed form, <br />written test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal <br />to the local regulatory agency. <br />2. TESTING CONTRACTOR INFORMATION <br />Name: <br />Technician Conducting Test: Jac. <br />Credentials: ❑ CSLB Licensed Contractor PA03WRCB Licensed Tank Tester <br />License Type: I License Number: — / G..'rte. <br />Manufacturer Training <br />Manufacturer <br />Date <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: c <br />Pape 1 of 7 <br />Date: �,0 --03. <br />1/13/2003 <br />Component <br />o! <br />Dove <br />o000 <br />�ooto <br />0000 <br />0000 <br />©tom© <br />0000 <br />o©oma <br />o000 <br />0000 <br />©Doo <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: c <br />Pape 1 of 7 <br />Date: �,0 --03. <br />1/13/2003 <br />