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Underground Storage Tank System Tanks, Piping, & Spill Buckets <br /> Secondary Containment Certification Form Page 4 of <br /> Facility#: '2?/33 City: �J�Gc� e•/ Testing Contractor: �. �� 0-ox Test Date:I IVIIS71a <br /> Facility Address: D[ �(� Jkd�/��/�yi t�iontractor Address:�9 (C S Tech.Name: <br /> Y 0 7.--1� <br /> 5'14 r" <br /> UST Annular Sp ace Secondary Piping S"t¢r+4 AOO <br /> Tank#1 Tank #2 Tank#3 Tank#4 Line#1 Line #2 Line#3 Line#4 <br /> Product 87 89 91 D 87 89 91 D 87 89 91 D 87 89 91 D Product 87 89 91 D 87 89 91 D 7 89 91 D 87 89 91 D <br /> Capacity Piping Type Prim Siphon Primary Siphon Primary iphon Primary Siphon <br /> Manufacturer Manufacturer <br /> Test Start Time Test Start Time ,00 1/0,kip <br /> Initial Pressure Initial Pressure '2 W0A1 t <br /> Test End Time Test End Time <br /> .00 •4 / ce <br /> Final Pressure Final Pressure <br /> Test Results Pass Fail Pass Fail Pass Fail Pass Fail r S <br /> S <br /> Test Results Pass Fail Pass Fail Pass FailI Pass Fail <br /> Signature <br /> Signature gAR44��—e%--� '�/—=6 <br /> Spill Buckets 5-y b>* y -to to-TtOe, Seo <br /> Overfill#1 Overfill#2 Overfill#3 Overfill#4 <br /> Secondary Pi in ~du C'64 <br /> Product 87 89 91 D 87 89 91 D 87 89 91 D 87 89 91 D ine#5 ine #6 Line#7 Line#8 <br /> Product 87 89 D 87 89 91 D 87 8 91 87 89 91 D <br /> Manufacturer 91 <br /> Piping Type ri ary iphon Primary Siphon Primary iphon Primary Siphon <br /> Start Time(to) Manufacturer4a /40 <br /> `` <br /> Water Level Std i k441n � <br /> Time(t,) Test Start Time <br /> °, <br /> Water Level �-" <br /> Initial Pressure ° .t J° t� S <br /> Time(t2) <br /> Water Level Test End Time .�t7 &"00 y <br /> Time 03) Final Pressure <br /> Water Level S "e <br /> Time 04) Test Results Pass Fail Pass Fail Pass a!L1 Pass Fail <br /> Water Level Signature Vf 56. <br /> Test Results Pass Fail Pass Fail Pass Fail Pass Fail <br /> Signature m <br /> Rev. 11/01 White-Original Yellow-Arco Environmental Compliance Pink-Contractor <br />