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Underground Storage Tank System <br />Secondary Containment Certification Form <br />Under Dispenser Containment <br />Page-, of <br />Facility ID: C -o Testing Contractor: CG{� �P0 Box, Iii 5'9 Test Date: <br />Facility Address: ��o fwd, S4 CA we --f Contractor Address: -�prr ��ojlo•rl C6 _ Tech. Name: <br />go LP n C 4-L Li c.L- <br />Fuelin Position <br />9/0 <br />(e.g.. 1/2, 3/4, etc.) <br />Start Time (to) <br />Start Time (to) <br />Water Level�•r <br />Q3$, -w1 <br />�f UC''� <br />Of./) J2 <br />Time (ti) <br />Water Level <br />S,SI%r+ / <br />./ <br />l%�i✓�/ <br />Gs U'�� <br />710-11 <br />Time 02) <br />Water Level <br />� ®� <br />Time 03) <br />Water Level <br />,3 �•+� / <br />�%► / <br />✓��� <br />C <br />7�J�"% <br />Time (0�as3 <br />7*1- <br />/ Z <br />7�>� <br />Water Level <br />A <br />tV5 A PI^ <br />Test Results <br />ssFail <br />as Fail <br />Pass <br />Cas Fail <br />Signature <br />1 <br />Fueling Position <br />9/0 <br />(e.g., 1/2. 3/4, etc.) <br />Start Time (to) <br />Water Level <br />Q3$, -w1 <br />Time (t,) <br />Water Level <br />Time 02) <br />Water Level <br />Time 03) <br />Water Level <br />Time 04) <br />1 <br />Water Level <br />Ip 5 PI^ <br />Test Results <br />ass Fail <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />[Signature <br />Fueling Position <br />(e.g., 1/2, 3/4, etc.) <br />Start Time (to) <br />Water Level <br />Time (t,) <br />Water Level <br />Time (t2) <br />Water Level <br />Time (t3) <br />Water Level <br />Time (t4) <br />1 <br />Water Level <br />Test Results <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Signature <br />Fueling Position <br />(e.g., 1/2, 3/4, etc.) <br />Start Time (to) <br />Water Level <br />Time (tj) <br />Water Level <br />Time (t2) <br />Water Level <br />Time (t3) <br />Water Level <br />Time 04) <br />1 <br />Water Level <br />Test Results <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Signature <br />Rev. 10/0l White - Original Yellow - Arco Environmental Compliance Pink - Contractor <br />