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Underground Storage Tank System Tanks, Piping, Tank Sumps & Overfill Buckets <br />Secondary Containment Certification Form <br />Page _� of 3 <br />Facility ID. Testing Contractor: t�Gi4�D X %u 0 9 Test Date: <br />Facilitv Address:/�/�i�/a S`T Contractor Address:,l__ _ Tech. Name: <br />ST'OC,� tOtsll C'� AL_ &C- /OOL <br />fPVT Annu/nr.4nnoo <br />Overrli R wilmo r^r <br />Tank #1 <br />Tank #2 <br />Tank #3 <br />Tank #4 <br />Product <br />87 89 91 D <br />87 89 91 D <br />87 89 91 D <br />87 89 91 D <br />Capacity <br />�Q S <br />O <br />' <br />Time (t2) <br />Water Level <br />Test Start Time <br />74o*/ <br />Time (t3) <br />Water Level <br />Initial Pressure <br />AN5 <br />Time (t,) <br />Water Level <br />Test End Time <br />7yyj� <br />S/OMS/ <br />O p <br />Test Results <br />Final Pressure <br />.�tff 7-4s -Y <br />%SJ <br />Pass Fail <br />Test Results <br />Test Results <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Signature <br />Overrli R wilmo r^r <br />Turhine Sumns <br />i <br />Tank #1 <br />Overfill #1 <br />Overfill #2 <br />Overfill #3 <br />Overfill #4 <br />Product <br />659 91 D <br />(189 91 D <br />87 899 <br />87 89 91 D <br />Start Time (to) <br />Water Level <br />�Q S <br />O <br />' <br />Time (t2) <br />Water Level <br />Time (ti) <br />Water Level <br />74o*/ <br />Time (t3) <br />Water Level <br />Time (t2) <br />Water Level <br />AN5 <br />Time (t,) <br />Water Level <br />Time 03) <br />Water Level <br />7yyj� <br />S/OMS/ <br />O p <br />Test Results <br />Time (ta) <br />Water Level <br />.�tff 7-4s -Y <br />%SJ <br />Pass Fail <br />Test Results <br />as Fail <br />ass Fail <br />as Fail <br />Pass Fail <br />Signature <br />Turhine Sumns <br />i <br />Tank #1 <br />Tank #2 <br />Tank #3 <br />Tank #4 <br />Start Time (t(j) <br />Water Level <br />Product <br />87 89 91 D <br />87 89 91 D <br />87 89 91 D <br />Time (ti) <br />Water Level <br />Test Start Time <br />Time (t2) <br />Water Level <br />Initial Pressure <br />Time (t3) <br />Water Level <br />Test End Time <br />Time (t,) <br />Water Level <br />Final Pressure <br />Test Results <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Signature <br />Signature <br />Secondary PivinQ <br />Rev. 10/01 White — Original Yellow — Arco Environmental Compliance Pink — Contractor <br />Line #1 <br />Line #2 <br />Line #3 <br />Line #4 <br />Product <br />87 89 91 D <br />87 89 91 D <br />87 89 91 D <br />87 89 91 D <br />Test Start Time <br />Initial Pressure <br />Test End Time <br />Final Pressure <br />Test Results <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Signature <br />Rev. 10/01 White — Original Yellow — Arco Environmental Compliance Pink — Contractor <br />