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Underground Storage Tank System Tanks, Piping, & Spill Buckets <br />Secondary Containment Certification Form Page / of <br />Facility #: City: _57�7 Q 64, Testing Contractor: �. G_ �, 1/0. &X /"5 'est Date: S <br />Facility Address: Contractor Address: eyu,. S Tech. Name: <br />UST Annular S ace <br />0', v <br />Spill Buckets <br />Tank #1 <br />Tank #2 Tank #3 Tank #4 <br />Product in <br />89 91 D <br />87 89(5 D 870 91 D 87 89 91 D <br />Capacity <br />V 0000?00z) <br />2 paQ <br />M facturer <br />4j,�ys <br />Com <br />Test Start Time <br />:Pa <br />Primary Siphon <br />Initial Pressure <br />q <br />d �C <br />''�►� <br />Test End Time <br />Y <br />Time (ti) <br />Final Pressure <br />(/ 7 0&nL u <br />Test Results <br />Pass Fail <br />Pass Fail ass Fail Pass Fail <br />Signature <br />0', v <br />Spill Buckets <br />Secondary Pi in <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 />87 591 D <br />87 89 91 D <br />Manufacturer <br />10 <br />Test Start Time <br />:Pa <br />Primary Siphon <br />St__ � Time (to) <br />Water Level/ <br />q <br />d �C <br />''�►� <br />���'�+ k <br />Y <br />Time (ti) <br />y%1� /`" L <br />(/ 7 0&nL u <br />v�� r�+ C <br />l <br />Test Results <br />Water Level <br />Pass Fail <br />Signature <br />Time (t2) <br />yeSV /W t <br />40 <br />'2400"( <br />Water Level <br />.titL <br />Time (t3) <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Water Level <br />Time 04) <br />f0 -s <br />b% 7 <br />' <br />2 <br />Water Level <br />/� <br />&.1 <br />Test Results <br />Pass ail <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Signature <br />Secondary Pi in <br />Secondary Piping <br />Line #1 Line #2 Line #3 <br />Line #4 <br />Product87 <br />9 91 D 87 89�D 87 89 1 D <br />87 89 91 D <br />Piping Type <br />Primary Siphon Primary SiphonPrimary Siphon <br />Primary Siphon <br />Manufacturer <br />'O"CAW Am"" /4^afty <br />Primary Siphon <br />Test Start Time <br />:Pa <br />Primary Siphon <br />Initial Pressure <br />Test End Time <br />Y <br />Test Start Time <br />Final Pressure <br />SaZ %5—'14sl <br />Test Results <br />Pass Fail ass Fail Pass Fail <br />Pass Fail <br />Signature <br />Secondary Piping <br />Rev. 11/0 1 White — Original Yellow <br />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 />Rev. 11/0 1 White — Original Yellow <br />Arco Environmental Compliance Pink — Contractor <br />