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MTJ��i <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 ownerloperatorfor submittal to the local regulatory agency. <br />cc <br />Facility Contact: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector ffPresent during testing): <br />3- 19111vArA1?,V OF —1 EST 7,.-ESULTS <br />if hg tic testing was performed, describe what was done widi the water after completion of tests: <br />AE, /4 e r h4 <-: A Z Arl--Q -Zad k <br />CERTMCATION OF TECHNICL4,N RESPONSIBLE FOR CONDUCTING TMS TESTING <br />!o. the best of my knowledge, tkefacts stated in dds document are accurate and injull compfiance with legal requirements <br />Date: <br />Technician's Signature: <br />- - - - - - - - - - - - - - - - - - <br />N I I Ltj <br />a�aaaaa <br />aa�aaaa <br />a�a�aaa� <br />as®aa <br />mom <br />a�a�aaa <br />mom <br />am®aal <br />a0a®aa <br />aaoaa <br />if hg tic testing was performed, describe what was done widi the water after completion of tests: <br />AE, /4 e r h4 <-: A Z Arl--Q -Zad k <br />CERTMCATION OF TECHNICL4,N RESPONSIBLE FOR CONDUCTING TMS TESTING <br />!o. the best of my knowledge, tkefacts stated in dds document are accurate and injull compfiance with legal requirements <br />Date: <br />Technician's Signature: <br />