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CD <br />0 <br />0 <br />CI <br />M <br />Underground Storage Tank System Turbine Sumps, Fill Sumps and Under Dispenser Containment <br />Secondary Containment Certification Form Page 2 -of �. <br />Facility #: City: _:1� 91� _ Testing Contractor: c�Test Date;//, /5;/-ot <br />Facility Address: le'? 5 � �S' � � Contractor Address: ��j f'� a Tech. Name: j(4 <br />Turbine Sumps <br />T> 89 91 1) <br />87 899F, D <br />87 89 91 D <br />87 '89 91 D <br />ID (north, slave, etc.) <br />-016 <br />Start Time (to) <br />t CI <br />Manufacturer <br />Time (ti) <br />� t' 2, <br />'�7 •rG..y� <br />Water Level <br />Start Time (to) <br />I — <br />L iF <br />0 <br />tU <br />® <br />Water Level <br />M <br />Test Results <br />U <br />W <br />93 <br />Signature <br />Time(t ,) <br />Water Level <br />Time (t2) <br />Water Level <br />Time (t3) <br />i <br />Water Level <br />9� <br />Time (t j <br />Water Level <br />Test Results <br />Pa Failass <br />Fail <br />Pass Fail <br />Pass Fail <br />Signature <br />Y 0/J <br />.66 <br />'t3 <br />UDC <br />87 89 91 D <br />IID (1/2, 3/4, etc.) <br />Manufacturer <br />-016 <br />Start Time (to) <br />t CI <br />Water Level <br />Time (ti) <br />� t' 2, <br />'�7 •rG..y� <br />Water Level <br />Time (t2) <br />Water Level <br />Q <br />C9 <br />Time (t3) <br />Water Level <br />0 <br />tU <br />® <br />Time (t,) <br />Water Level <br />CD <br />^° <br />Test Results <br />U <br />W <br />93 <br />Signature <br />.66 <br />'t3 <br />87 89 91 D <br />87 89 91 D <br />87 89 91 D <br />ID nor(slave etc. <br />) <br />t CI <br />Manufacturer <br />oq <br />� t' 2, <br />'�7 •rG..y� <br />Start Tline (to) <br />'3 Fail <br />ass Fail <br />7- <br />Fail I ass . Fail <br />Fill Sumps <br />J F \.! <br />87 89 91 D <br />87 89 91 D <br />87 89 91 D <br />ID nor(slave etc. <br />Manufacturer <br />oq <br />Start Tline (to) <br />Fail I ass . Fail <br />Fill Sumps <br />87 89 91 D <br />87 89 91 D <br />87 89 91 D <br />87 89 91 D <br />ID nor(slave etc. <br />Manufacturer <br />Start Tline (to) <br />Water Level <br />Time (tj <br />Water Level <br />Time (t2) <br />Water Level <br />Time (t3) <br />Water Level <br />Time (ty) <br />Water Level <br />Test Results <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Signature7. <br />UDC <br />ID (1/2,3/4, de.) <br />Manufacturer <br />Start Time (to) <br />Water Level <br />Time (ti) <br />Water Level <br />Time (t2) <br />Water Level <br />Time (t3) <br />Water Level <br />Time (Q <br />Water Level <br />Test Results Pass Fail Pass Fail Pass Fail Pass Fail <br />Signature <br />Rev. 11/01 White — Original Yellow — Arco Environmental Compliance Pink — Contractor <br />