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Underground Storage Tank System Tanks, Piping, Tank Sumps & Overfill Buckets <br />Secondary Containment Certification Form <br />Page / of / <br />Lk .11 <br />Facility ID: _ 1 Testing Contractor: e,-,- / a/7a�i �y� Test Date: /a /g -o/ <br />Facility Address: —5A C G� vvl/ ' Contractor Address: C..ClI �l (�/f _ Tech. Name: ��pti t,c,La, <br />57`0Ck7--0 ki c6t- CAC- &C /oaz <br />INT Annular Rmyro <br />nvnrrll Rm-knlc <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 />1115eY"t <br />Time (ti) <br />Test Start Time <br />Water Level <br />i <br />Initial Pressure <br />Time (t2) <br />Water Level <br />Test End Time <br />Time (t3) <br />Final Pressure <br />Pass Fail <br />Water Level <br />Pass Fail <br />Pass Fail <br />Test Results <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Signature <br />"05 $ Py <br />SOS g P <br />Test Results <br />nvnrrll Rm-knlc <br />Turhine Sumns <br />Overfill #1 <br />Overfill #2 <br />Overfill #3 <br />Overfill #4 <br />Product <br />87 89 91 D <br />87 89 91 D <br />87 89 91 D <br />87 89 91 D <br />Start Time (to) <br />1115eY"t <br />Time (ti) <br />Water Level <br />Water Level <br />Time (ti) <br />Time (t2) <br />Water Level <br />Water Level <br />Time (t3) <br />Time (t2) <br />Pass Fail <br />Water Level <br />Pass Fail <br />Pass Fail <br />Water Level <br />Time (ta)- <br />Time (t3) <br />"05 $ Py <br />SOS g P <br />Test Results <br />Water Level <br />Pass Fail <br />Pas, Fail Pass Fail <br />Signature <br />Time (ta) <br />Water Level <br />Test Results <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Signature <br />Turhine Sumns <br />Secondary Pining <br />Tank #I <br />Tank 92 <br />Tank #3 <br />Tank #4 <br />Start Time (to) <br />87 89 91 D <br />87 89 91 D <br />87 89 91 D <br />Water Level <br />DO fjP49 <br />1115eY"t <br />Time (ti) <br />Initial Pressure <br />Water Level <br />- <br />Time (t2) <br />Water Level <br />pC3 (, " <br />Time (t3) <br />Test Results <br />Pass Fail <br />Water Level <br />Pass Fail <br />Pass Fail <br />Signature <br />Time (ta)- <br />Water Level <br />"05 $ Py <br />SOS g P <br />Test Results <br />ass Fail <br />Pass Fail <br />Pas, Fail Pass Fail <br />Signature <br />Secondary Pining <br />Rev. 10/01 White - Original Yellow - Arco Environmental Compliance Pink - Contractor <br />Line #I <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 />