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Underground Storage Tank System Tanks, Piping, & Spill Buckets <br />Secondary'Containment Certification Form Page of <br />toWCA 1 <br />Q Facility #:fir! City: ��`!�') _Testing Contractor: /moi Test Date: //- /`�%��''c. <br />Facility Address: �� •�� Contractor Address:Name:�� _ <br />in in <br />in <br />Q <br />Cn <br />CD <br />0 <br />CU <br />0 <br />cn <br />U <br />d <br />FI4T Aetaatlarr Nnarn <br />Tank 41 <br />Tank #2 <br />Tank #3 <br />Tank #4 <br />Product C8 7T 89 91 D <br />87 89 91 D <br />87 89 91 D <br />87 89 91 D <br />Capacity <br />87 89 91 D <br />Manufacturer <br />Primary Siphon <br />Manufacturer <br />Test Start Time , <br />I� <br />Start Time (to) <br />Water LevelCly <br />Initial Pressure. <br />zc i <br />Test End Time j <br />Initial Pressure <br />Test End Time <br />jl ' <br />%G- 2,3 <br />Final Pressure <br />Time (t2)t <br />Water Level <br />J' ``7 <br />OD <br />Z <br />Test Results as Fail <br />Signature <br />Pass }Fail <br />Pass Fail <br />Pass Fail <br />/Z-1' .Z <br />Pass Fail <br />Signature <br />Shill Buckets <br />Secanrlary Pinuzrr <br />t9 i �i I'S •M IN C.11 <br />Line #1 Line #2 <br />Overfill #1 <br />Overfill 42 <br />Overfill #3 <br />Overfill #4 <br />Product <br />089 91 D9 <br />9_; D <br />87 89 91 D <br />87 89 91 D <br />Manufacturer <br />Primary Siphon <br />, <br />I� <br />Start Time (to) <br />Water LevelCly <br />Test Start Tim, <br />zc i <br />Test End Time j <br />Initial Pressure <br />Time (t,) <br />Water Level <br />jl ' <br />%G- 2,3 <br />Test Results �t: Fail § Fail <br />Time (t2)t <br />Water Level <br />J' ``7 <br />OD <br />Z <br />Time (t3) <br />Water Level <br />i l r F <br />/Z-1' .Z <br />Pass Fail <br />Signature <br />Time (t.,) <br />Water Level <br />_� <br />j ? <br />Test Results <br />ass Fail <br />Pas Fail <br />Pass Fail <br />Pass Fail <br />Signature <br />Secanrlary Pinuzrr <br />t9 i �i I'S •M IN C.11 <br />Line #1 Line #2 <br />Line #3 <br />Line #4 <br />Product 8 89 91 D 31 D <br />87 89 91 D <br />87 -89 91. D <br />Piping Type Irim Sipho im Siphon <br />Primary Siphon <br />Primary Siphon <br />Manufacturer <br />Prim ' Siphon Primary Siphon <br />Primary Siphon <br />Test Start Time ' "D --Q <br />I� <br />Initial PressureZD <br />Test Start Tim, <br />` VrA <br />Test End Time j <br />Initial Pressure <br />Final Pressure <br />-f 7 _ —1 <br />Test End Time <br />Test Results �t: Fail § Fail <br />Pass Fail <br />Pass Fail <br />Signature <br />SeconrlarvKDML, n,cr, 'Tn. V\ cry <br />Rev. 11/01 White — Original Yellow — Arco Environmental Compliance Pink — Contractor <br />Line 45 <br />Line #6 Line #7 <br />Line #8 <br />Product <br />87 89,fq D <br />87 89.• I�1 D 87 89 91 D <br />87 89 91 D <br />Piping Type <br />ima ; Siphon <br />Prim ' Siphon Primary Siphon <br />Primary Siphon <br />Manufacturer <br />I� <br />Test Start Tim, <br />` VrA <br />Initial Pressure <br />Test End Time <br />M <br />Final Pressure <br />Test Results <br />ass" Fail <br />ads Fail Pass Fail <br />Pass Fail <br />Signature <br />_� <br />Rev. 11/01 White — Original Yellow — Arco Environmental Compliance Pink — Contractor <br />