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Underground Storage Tank System Tanks,Piping,& Spill Buckets <br /> Secondary Containment Certification Form <br /> Page - of �-- <br /> Facility i#: city: Mle(ck <br /> L Testing Contractor: n C Teat Date: A! $ . Z <br /> Faeifity Address; YD t ST Contractor Address. 1�f �•�f7q wtpac A Tech. Name: &C <br /> UST AnnularS ace Secarrda Pin <br /> Tank 9] Tank #2 Tan><#3 Tank#4 L1oe111 Line #2 Linr#3 <br /> L[ne#4 j <br /> Product 87 (D 91 D 7 U 91 D 87 99(5 D 87 89 91 D Product 87 89 91 D 9 9) D 87 891 D 87 89 41 D <br /> Capacity OtaD p dQt7 ' <br /> Piping Type nm Siphon im Sirhon Primary Siphon Primary Siph <br /> Manufacturer ;QVt <br /> 4 � <br /> � �fi�es Manufacturer A^"re-r°^ Y�142 ren Rrv�eror-ti <br /> Test Start Time <br /> Test Start The <br /> Initial Pressure � '� (Q^ IJ?YCUr /D��a tfu�fEU1' tQelCdl IniiialPresaure <br /> Test End Time 61 27 <br /> ` f Test End Time ' <br /> Final Pressure 1 fl" 10"MzYLU t p�l�efrV t - <br /> Final Pressure moo+ pro - no} <br /> Test Results ass Fail Fait Fail s Fait 'lxbie ble <br /> Signature . 1)(91 Test Results Pass it Pass Fai Pass Fait Pas Fail <br /> geo e.q <br /> Signature � b'r � �t dC 2_ <br /> S 111 Buckets <br /> OverflH#I Overfill#2 Overfill#3 Qverfi)i#4 Second P in <br /> Product 87 89 91 D 87 89 91 D 8 89 91 D 87 89(9 D Line#5 Line #b Line#7 Line#8 <br /> Manufacturer Meed Fa►wC0 {oMQCO ��M2C0 Product 87 89 91 D 87 89(0 I) 87 89 91 D 87 89 91 D <br /> Start Time(tj H:: 2 7 2 ; Off, 1 �',{ Piping Type Primary hon Prirn Primary SiKhon Primary Siphon <br /> Water levelODD +0 <br /> i0a� 0o0G ,000 �4Manufacturer <br /> Time :3'L r Z 'os- 12 '/7. / Z2 "�'� hn,t ro n <br /> Water Level Test Start Time <br /> pvo o,a 0 c.l 0,03) - 0. 2 6 4 i :� <br /> f Time(t,) 11 : 35- / 2 ; p 8 Initial Pressure S',6 o5i <br /> Water Level 0-col P Test End Timer <br /> Time{i,) ti : 38 I:S T <br /> /2 :?J Final Pressure <br /> Water Level _a�ooZ a. S-0 jrQ <br /> Time(t,,) t t:t�� 1� ,� TatRe3ults Fail <br /> Water Level Fail Pass Fait Pass Fail <br /> Signature <br /> Test Results Fail Pass C a Pass Fail Pa9s ai <br /> Signature .G9't irnt, <br /> Yv `� <br /> Rev. 1 1/01 White–Original Yel low–Arco Environrnenta[Compliance Pink–'Contractor <br />