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Underground Storage Tank System Tanks, Piping, & Spill Buckets <br />Secondary Containment Certification Form Page / of <br />Facility #: City: ��� k72Testing Contractor: �. A`;� �jp��ZyVest Date: <br />Facility Address: Contractor Address:Tech. Name: <br />"I cP-Ke a #i m .. <br />UST Annulnr .Cnnro <br />Shill Ruck.,ty <br />Tanlc #1 <br />Tank #2 <br />Tank #3 Tank #4 <br />Product <br />89 91 D <br />87 89 9 D <br />87 89 91 D 87 89 91 D <br />Capacity <br />000 <br />4?0,00 <br />1,2 dao <br />Ma^ �facturer <br />Test Start Time <br />O l� <br />C1O1rC•�/ <br />S Time (to) <br />Water Level <br />Initial Pressure <br />N A) - <br />A <br />Test End Time <br /><'AS— <br />,5. o� •� V sl S a PS:Z <br />Final Pressure <br />D4, d4 <br />�.Sl% N� L <br />// <br />�40 rt,+r( <br />Test Results <br />Pass Fail <br />Pass Fail <br />ass Fail Pass Fail <br />Signature <br />Time (t4) <br />Water Level' <br />Shill Ruck.,ty <br />Rev. 11/01 <br />Secondary Pining <br />Overfill #1 <br />Overfill #2 <br />Overfill #3 <br />Overfill #4 <br />Product <br />87 9 91 D <br />87 89 91 D <br />87 89 91 D <br />87 89 91 D <br />Manufacturer <br />Primary Siphon <br />Test Start Time <br />O l� <br />Primary Siphon <br />S Time (to) <br />Water Level <br />q <br />700r4,-�- <br />Time (t,) <br />Water Level <br />0- L <br />,5. o� •� V sl S a PS:Z <br />Test Results <br />Time (t2) <br />Water Level <br />�.Sl% N� L <br />// <br />�40 rt,+r( <br />jk <br />Time (ts) <br />Water Level <br />Time (t4) <br />Water Level' <br />, <br />Pass ail <br />Pass Fail <br />Test Results <br />Pass ail <br />Pass Fail <br />Signature <br />Pass Fail <br />Signature <br />Rev. 11/01 <br />Secondary Pining <br />Secondary Pining <br />Line #1 Line #2 Line #3 <br />Line #4 <br />Product <br />87 9 91 D 87 8901 D 871 D <br />87 89 91 D <br />Piping Type <br />Primary Siphon Primary Siphon I Primary Siphon <br />Primary Siphon <br />Manufacturer <br />Piping Type <br />Primary Siphon <br />Test Start Time <br />/ �:00 ,.� g►�+� f �'jp <br />Primary Siphon <br />Initial Pressure <br />Test End Time <br />Test Start Time <br />Final Pressure <br />,5. o� •� V sl S a PS:Z <br />Test Results <br />Pass Fail ass Fail Pass Fail <br />Pass Fail <br />Signature <br />jk <br />Secondary Pining <br />L - <br />White — Original Yellow — Arco Environmental Compliance Pink — Contractor <br />Line #5 <br />Line #6 <br />Line #7 <br />Line #8 <br />Product <br />87 89 91 D <br />87 89 91 D <br />87 89 91 D <br />87 89 91 D <br />Piping Type <br />Primary Siphon <br />Primary Siphon <br />Primary Siphon <br />Primary Siphon <br />Manufacturer <br />Test Start Time <br />Initial Pressure <br />Test End Time <br />Final Pressure <br />Test Results <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Signature <br />L - <br />White — Original Yellow — Arco Environmental Compliance Pink — Contractor <br />