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Underground Storage Tank Syttem Tanks,Piping, & Spilt Buckeft <br /> Secondary Containment Certification Form Page 2 of 2 <br /> tt� <br /> Facility#: 133 City: S TOG Ib--dw) Testing Contractor: pn4rael ICA S4nr,, Test Date: <br /> Facility Address: Z_lOff �Gfmirn hr. Contractor Address:14�j�( ,S S,�� Ac__ Tech.Name: lams <br /> ft 5-0 <br /> ilSTAnnularace Second <br /> Tank#f Taitk 42 Tank#3 'Tank#4 Lice#1 Line #2 Line#J3 Line#4 <br /> Product 67 69 91 D 87 99 91 D 97 89 91 D:: 87 89 91 D Product . 99 9.1 D 87 89 91 D 87 89 91 D 87 89 91 D <br /> Capacity , pjpWg. y'pe. Primary siphon Primary Siphon Primary Siphon Primary siphon <br /> Manufacturer Ma�afaetnrer <br /> .a Sr,i <br /> Test Start Time TestMart'note <br /> lnitW Pressare Initial Pressure <br /> Test End Timefest.End.Time <br /> Ci;30 <br /> Float Pressure <br /> Final Pressure - S.0 RS.I' <br /> Test Results Pass Fail Pass Fail Pass Fail Pass Fail <br /> Test Resalb Fat'( Pass Fail Pass Fail Pass Fail <br /> Signature 04 <br /> Si�imtare <br /> S ill Buckets <br /> Overfill#1 Overfill#2 Overfill#3 Overfill 94 <br /> Product 87 99 91 D 97 89 91. D 87 89 91 D 87 89 91 D Line#S Line #6 Line t#7 Line#S <br /> Product '87 89 91 D 87 89 91 D 87 89 91 D 87 89 91 D <br /> Manufaeturer <br /> -Ploing Type -Primary Siphon Primary Siphon Primary Siptwn Primary Siphon <br /> Start Mme{!q) <br /> Water Level MI <br /> Time(t,) Test`Start Time <br /> Water Level <br /> ''nine(t,) Initi�lPre�avt`e <br /> Water Level Tedt$iffd` 'inre <br /> 1 <br /> Time(t3) Final <br /> Water Level <br /> Time(tj Test Results Pass Fail Pass Fail Pass Fail Pass Fail <br /> Water Level Signature XAC <br /> Teat Results Pass FiiI I Pass Fail Pass Fail Pass Fail <br /> S'�gnatnre 11 <br /> Rev.1 MI White—Original Yellow—Arco Enviranmerital Compliance Pink—Contractor <br />