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Underground Storage Tank System Tanks, Piping, & Spill Buckets <br /> Secondary Containment Certification Form Page L of <br /> Facility#:_&_7j 3r City: JTaOtTo N Testing Contractor: krAf-y N Test Date: WtAre,k t Z a..Z„ <br /> Facility Address: A'f g 18$ 3owth S44 ire, Qo.t6 41 Contractor Address: 674 Z %;trrti Cl- 040.7 Tech.Name: 6.r k VK'AC.0 <br /> UST Annular Sp ace Seconda Pi in <br /> Tank#1 Tank #2 Tank#3 Tank 44 Line#j Line #2 Line#3 Line#4 <br /> Product 089 91 D 87 91 D 87 89 1 87 89 91 D Product 87 W91 D 7 89 eD 7® 9 91 D 87 ®91 D <br /> Capacity j c),000 000 &OcPiping Type Pri hon Pn_'mary ipho 'mart' Siphon Primary Siphon <br /> Manufacturer Manufacturer 'F.n <br /> Aw. ron AW+ n Gln+ ro <br /> Test Start Time t{O O q 1 0( 3(7 Test Start Time <br /> 42.10 9ti"Z- ►2C7o t1 OCZ <br /> Initial Pressure ttj,1 IOt►H6 1 C)11 14r. Initial Pressure <br /> g PJz c, PSr' PJ.'C 5 vaL <br /> Test End Time %0,6-0 101.5 Test End Time <br /> tOLO ►O '-lZ, tZOO <br /> Final Pressure (Olt 1-LG to"14f* to"Af. <br /> Fi1111� nal Pressure QJZ rjPSS j tSL 4J= <br /> Test Results Pass Fail Pass Fail ass Fail Pass Fail <br /> Test Results Pass Fail Pass Fail Yals Fail Pas Fail <br /> Signature y,� <br /> Signature 0l✓— <br /> Spill Buckets <br /> Over ill#1 Overfill#2 Overfill#3 Overfill#4 econdary Pi in <br /> Product 89 91D 87 &61 D 87 89 9 D _9 91 D Line#5 Line #6 Line#7 Line#8 <br /> Product 87 89 1 D 87 89 91 D 87 89 91 D 87 89 91 D <br /> Manufacturer OM CC 0 94wtr1_0 <br /> l <br /> Piping Type Prim Primary Priy Siphon Primary Siphon Primary Siphon <br /> Start Time(ta) t t p 164 -5 11 3 5 <br /> Water Level 000 a.00$ 1 oao `000 Manufacturer <br /> Time(t,) 11633FailPass <br /> 1051 11 37 Test Start Time <br /> Water Level _oy — 010 1� 0 <br /> Time(t2) 0 54 "31 Initial Pressure 6— <br /> Water Level — 0 3 Test End Time <br /> Time(ta) O X) Final Pressure 6-Water LevelTime(ta) Test Results Pass ar Pass Fail Pass Fail Pass Fail <br /> "Water Level SignatureTest Results s Fail Pass Fajl Pass Fai`� <br /> Rev. 11/01 White-Original Yellow-Arco Environmental Compliance Pink-Contractor <br />