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Underground Storage Tank System <br />Secondary Containment Certification Form <br />Under Dispenser Containment <br />Page -,3 of 3 <br />Facility ID: ,�j Q#c�✓�� Testing Contractor: �R5 P© IX Test rate: a /;/-471 <br />Facility Address: .3i?/�/GG,/.yhiG S%- Contractor Address: Tech. Name: <br />CAL. 6-C. / oo-z-� <br />Fueling Position <br />(e.g., 1/2, 3/4, etc.) <br />Start Time (t(,) <br />Water Level <br />m <br />Time (tr) <br />Water Level <br />Time (t2)Lis <br />Water Level <br />Time (t3) <br />Water Level <br />Time (0 <br />1,CyjM <br />eSS Tfie-� <br />�tsS �ieH <br />�GSsTGi� <br />Water Level <br />SUS 5Pl <br />Pk <br />ps gpti <br />OS <br />Test Results <br />Pass Fail <br />P s Fail <br />Pass) Fail <br />ass Fail <br />Signature <br />Water Level <br />A <br />Fueling Position <br />(e.g., 1/2, 3/4, etc.) <br />Start Time (to) <br />Water Level <br />Time (ti) <br />Water Level <br />Time (t,) <br />Water Level <br />Time (t3) <br />Water Level <br />Time (t4) <br />Water Level <br />Test Results <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Signature <br />I1T, <br />Fueling Position <br />(e.g., 1/2, 3/4, etc.) <br />Start Time (to) <br />Water Level <br />Time (tr) <br />Water Level <br />Time (t2) <br />Water Level <br />Time (t3) <br />Water Level <br />Time (t4) <br />Water Level <br />Test Results <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Signature <br />I1T, <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 />Water Level <br />Test Results <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Signature <br />I1T, <br />Sz <br />Rev. 10'01 White - Original Yellow - Arco Environmental Compliance Pink - Contractor �) <br />?-") I21%0> <br />