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n U;� 0V90 <br /> Underground Storage Tank System Tanks, Piping, & Spill Buckets <br /> Secondary Containment Certification Form NOV 0 5 2002 Page__L of <br /> ENVIRONMENT HEALTH <br /> Facility#: tp 33 5 City: Z)TOQyrci h Testing Contractor: g kr,94•hrtr,..T�r 'TnL:Test Date: M rc it c z a. <br /> Facility Address: 1'f 813$ Jowth S+a ire, 12a,& 9 4 Contractor Address: (6,741 Coi err.. Ci- p„LL�Tech.Name: NSr r k Ml Ylr eH <br /> USTAnnularSpace Seconda Pi in <br /> Tank#1 Tank #2 Tank#3 Tank#4 Line#j Line #2 Line#3 Line#4 <br /> Product 619 91 D 87 Q'91 D 87 89 E% 87 89 91 D Product 87 W91 D 87 89 eD 9 91 D 87 ®91 D <br /> Capacity I O 00 000 &OU Piping Type Prim Siphon Pn_'m$ry ipho 'many Siphon Primary Siphon <br /> nufacturer - Manufacturer '�+•n <br /> 4.4 Aw. r A„+ ro✓I l�r+ ro r <br /> Test Start Time g 0 0 Cl IS 0( 3(7 Test Start Time <br /> 42.0 9L►�- t2Oo I an <br /> Initial Pressure torr 1'16 10%1H6 10j1kr. Initial Pressure SpbII SpSL QJ= $ poL <br /> Test End Time 10-163-0 lots Test End Time % 07-0 t 0 `'1 Z Ito12 o O <br /> Final Pressure 1011 r4G 10"la b IO"Ar, <br /> Final Pressure QS'C rj PJr j f SL 4J= <br /> Test Results Pass Fail Pass Fail ass Fail Pass Fail <br /> Test Results Pass Fail Pass Fail ( ?asl Fail Pass Fail <br /> Signature <br /> Signature1�� <br /> Spill Buckets <br /> Over ll#1 Overfill#2 Overfill#3 Overfill#4 econdary Pi in <br /> Product 99 91 D 87 OKI D 87 89 9 D �9M91 D Line#5 Line 116 Line#7 Line#8 <br /> Product 87 89 1 D 87 89 91 D 87 89 91 D 87 89 91 D <br /> Manufacturer a CC ¢Go Puw1u o <br /> Piping Type Prim Siphon Primary Siphon Primary Siphon Primary Siphon <br /> art Time(to) I t 1 0 16't g 11 3 5 <br /> Water Level Opo -boo$ 06 -000 Manufacturer Q <br /> Time(tr) 1%13 1 0 j 1 11 3'1 Test Start Time O <br /> Water Level - 001 o y - 01 0 <br /> Time(t2) It l im to gy 031 9 Initial Pressure <br /> Water Level - oo l - 01,1,21 Test End Time <br /> Time(t3) 1119 10 T 7 Final Pressure 69- <br /> Water Level -0 Q__t ��';� <br /> Time(t4) vI vL' Test Results Pass OaJ Pass Fail Pass Fail Pass Fail <br /> Water Level be( Signature --- <br /> Test Results as Fail Pass Fail Pass Fajl Pass Fai 2 <br /> Signature r �� Jl <br /> Rev. 11/Dl White-Original Yellow-Arco Environmental Compliance Pink-Contractor <br />