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UNDERGROUND STORAGE TANK <br /> SECONDARY CONTAINMENT TESTING REPORT FORM (Page s of s) <br /> XVII. FILL RISER SUMP TESTING INFORMATION <br /> Manufacturer Identify Tank ID from Section III for each Manufacturer <br /> Fiberglass A ❑ I B Z I C ® D <br /> A ❑ I B ❑ I C ❑ D <br /> Test Method Used: ❑ Manufacturer Guidelines(Specify): <br /> ® Industry Code or Engineering Standard (Specify): Hydrostatic <br /> ❑Engineered Method(Specify): <br /> #of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> Fill Riser Sump Testing Training and Certifications(List applicable certifications.) Expiration Date <br /> ICC UST Certification#8819839 10/15/2021 <br /> INCON TS-STS L4-Certification# 1019623710 9/24/2020 <br /> XVIII. COMMENTS _ <br /> Provide any additional comments here. <br /> ri if L LJ <br /> DEC 17 2019 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> XIX. VENT/TRANSITION SUMP TESTING INFORMATION <br /> Manufacturer Identify Vent/Transition Sump ID from Section III for each Manufacturer <br /> a I b ❑ c ❑ d <br /> a I b ❑ I c ❑ d ❑ <br /> Test Method Used: ❑ Manufacturer Guidelines (Specify): <br /> ❑ Industry Code or Engineering Standard (Specify): <br /> ❑ Engineered Method (Specify): <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages <br /> Vent/Transition Sump Testing Training and Certifications (List applicable certifications.) Expiration Date <br /> XX. COMMENTS <br /> Provide any additional comments here. <br /> N/A <br /> ID=Identification <br />