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0 RECEJED <br />SWRCB,.January 2002 DEL 1 0 1009 Page — of <br />Secondary Containment Tes I <br />%Wlk <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages ofthis, 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 />1. FACILITY INFORMATION <br />2. TESTING CONTRACTOR INFORMATION <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, descnibe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the test of my knowledge, the facts stat this document are accurate and in full compliance with legal requirements <br />Technician's Signature:_ Date: <br />MM <br />12 1 .. <br />0000; <br />o�c�o <br />87 SEC LINEoor�o <br />oao�� <br />91 Sit LINE <br />87 STP SUMP <br />DISP 3-4 <br />DISP 5-6 <br />DISP 7-8 <br />ffvv�§ <br />I <br />If hydrostatic testing was performed, descnibe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the test of my knowledge, the facts stat this document are accurate and in full compliance with legal requirements <br />Technician's Signature:_ Date: <br />