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i <br />Underground Storage Tank System Under Dispenser Containment Page of 3 <br />Secondary Containment CertHiication Form II <br />'lest Date: <br />Testing Contractor: _ I ~ <br />Facility ID: � -e � 0 <br />,�/'�- �y�ss Cf> Tech, Name: <br />Contractor Address: CAC. Lr e, <br />Facility Address: 3J/� ��Ly��G ST # — <br />o <br />v Fueling Position y <br />Fueling Position 3/ (e.g., 1/2, 3/4, etc.) <br />(e.g.. 1/2, 3/4, etc.) <br />Start Time (to) � <br />Start Time (to) j��/ I a 5 ( �] f} „y.t Water Levet <br />Water Levet �� �i <br />Time <br />Time (t,) 7So� /s/�Q`„ / 8�0�!J Water Level - <br />Water Level ✓ �/ I ( --� I <br />Time (tZ) <br />Time 02) S -1 S f ��� ri Water Level - - -- —� <br />Water Level <br />Time (t,) <br />Time (t,) Off/ Water Level <br />Water Level v <br />Time (t4) <br />Time (t,) �CM p Water Level — <br />Water Level 10S 5P�^ 4,0$ � � �S g � � 5� <br />Pass Fail Pass Fail Pass Fail Pass Fail � <br />Test Results Pass Fail P Fail as Fail Test Results —� Fail— <br />Pass Fail ; <br />Signature <br />Signature <br />i <br />Fueling Position <br />Fueling Position (e.g., 1/2, 3/4, etc.) <br />(e.g., 1/2, 3/4, etc.) <br />Start Time (to) <br />Start Time (to) Water Level <br />Water Level y <br />Time (t,) <br />Time (t,) Water Level <br />Water Level <br />Time (t2) <br />Time (0 Water Level <br />Water Level <br />Time (y) <br />Time (W Water Level <br />Water Level <br />Time (t,) <br />Time (t4) Water Level <br />Water Level Pass Fait Pass Fail Pass Fail Pass Fail <br />Test Results Pass Fail Pass Fail Pass Fail Pass Fail Test Results �ITIV <br />' Signature <br />Signature S � <br />z o <br />0 <br />Yellow - Arco Environmental Compliance Pink - Contractor <br />White - Original <br />Rev. 10'01 <br />