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Underground Storage Tank System Turbine Sumps, Fill Sumps and Under Dispenser Containment 4 0 <br /> Secondary Containment Certification Form Page t of —2- <br /> 6 <br /> ! o <br /> Facility M ! CI I '1 / , <br /> Y 3 3 ty: �r1I�+v7 C Testing Contractor: �� (p11JC Test hate: <br /> r G <br /> 11Qd }} <br /> t facility Address: 5. /1'TQi!? ST Contractor Address: ��IIS 5. Zt7y/c <br /> x <br /> r <br /> �;y r <br /> Turbine Sumps 67 9 91 1) a 89 91 D 87 89�9 D 87 39 91 D Fill Sump$ 87 89 SD f�:)89 91 D 87 91 D 87 89 91 D <br /> 1D(north, slave,tic.) fi) north slave etc. o <br /> ManufacturerXQ;xS XQY Q5 (XQS Manufacturer <br /> Start Time(lc) 10: $'L 11 .Oio 11 2p Stort Time(h) <br /> Water Leve' i Water Level <br /> Time((j) l`b�( � �p1[ Time <br /> Water Level J ` 11 t . !, Water Level <br /> Time(12) k� QSX��� est"�i�' Time((I) <br /> Water Level Water Level �{ <br /> Time 03) Time(ts) <br /> Water Level Water Level <br /> Time(t,) Time(tt) <br /> Water Level Water Level � <br /> Test Results Pass Fail j Pass Fail Pass Fai s Fail Test Results Pass Fai[ Pass Fai Pass Fai P s Fail <br /> Signature v Signature <br /> 1/6 UDC / <br /> UDC � 2 � p ID{lrl,3f4,c1c.l $ �// <br /> JZ <br /> !D{IR,3/4,etc.) <br /> Manufacturer Amerced" rt'+er•can {�-Yr:¢t�c40 ,Fry1ers��+ Manufacturer <br /> C f r4 cb-k4;nm n ton "rrotrn� o(7�a,.r f <br /> Start Time(to) ' 2 �a Start Time(td) ,L� �- <br /> Water Level O.00C 0. 000 Water Level 0 000 ODp <br /> Time(ti) 2:30 Z-'0 �p� Time(t /• f ' rS <br /> Water Level �}�'t 0'OS �0.00� Water Level b� � �6 01 <br /> Time(tI) Time(t,) <br /> Water Level S1"PY' QS Weter Level <br /> Time (tj) Time(t3) <br /> Water Level Water Level <br /> Time (t,) Time(4) <br /> Water Level � Water Level <br /> Test Results Pass ail Pass Fail Pass Fa PassFail Test Results Pass Fail Pass Fai Pau Fai[ Pas Fail <br /> Signature UGC Signature Y v1�6 6 \ C <br /> 0 <br /> 1\ G <br /> Rev. I l OI While—Original Yellow—Arco Environmental C imnliancr p;w <br />