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Underground Storage Tank System Tanks, Piping, & Spill Buckets <br />Secondary Containment Certification Form Page I of <br />Facility #: sy4 y City: T�[ Gild �f� Testing Contractor: �. ' e0jQ &= /yAMest Date: ;z <br />Facility Address: %�� s. 4.�,F°GSC%C/ Contractor Address: F> G0�.4/S (_ d Tech.�l�lame: ` r' <br />) <br />UST Annular Space <br />lGTA, <br />Spill Buckets <br />Tank #1 <br />Tank #2 Tank #3 Tank #4 <br />Product <br />89 91 D <br />87 89(5 D 87 89 91 D 87 89 91 D <br />Capacity <br />q'iOGO <br />aQp� / a2 dao <br />Manufacturer <br />Manufacturer <br />Primary Siphon <br />. est Start Time <br />�. <br />40 <br />.�. Z' <br />Initial Pressure <br />D,IN <br />oo0zm/ A4 <br />Test End Time <br />V-050 <br />Final Pressure <br />40,W A <br />dA <br />Test Results <br />Pass) Fail <br />Pass Fail ass Fail Pass Fail <br />Signature <br />Final Pressure <br />S'% a?V <br />lGTA, <br />Spill Buckets <br />Rev. 11/0 1 <br />Secondary Piping <br />Overfill 41 <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 />�. <br />40 <br />Amwv .4^4ww <br />xt Time (to) <br />v✓ater Level <br />q <br />�/ d �C <br />:00 ^ <br />700M+ l <br />Time (tr) <br />Water <br />y7� / A. L <br />Z sow ja <br />Test End Time <br />Level <br />Y'&V ' 33-V <br />Final Pressure <br />S'% a?V <br />Time (t2) <br />Water Level <br />ysl% NSC <br />// <br />447'41 <br />Pass Fail <br />ass Fail Pass );ail <br />Time (t3) <br />Signature <br />Water Level <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Pass Fail <br />Time 04) <br />Water Level <br />�, <br />�� <br />Test Results <br />Pass ail <br />Pass Fail <br />Pass ail <br />Pass Fail <br />Signature <br />Rev. 11/0 1 <br />Secondary Piping <br />Secondary Pi in <br />Line #1 <br />Line #2 Line #3 <br />Line #4 <br />Product <br />87 9 91 D <br />87 89 1 D 871: l D <br />07 <br />87 89 91 D <br />Piping Type <br />Primary Siphon <br />Primary Siphon Primary Siphon <br />Primary Siphon <br />Manufacturer <br />n <br />Amwv .4^4ww <br />Manufacturer <br />Test Start Time <br />:00 ^ <br />9.160,40,14%x'30 <br />Initial Pressure <br />S—, <br />Z sow ja <br />Test End Time <br />>10 OD <br />Y'&V ' 33-V <br />Final Pressure <br />S'% a?V <br />SC S a PSS <br />Test Results <br />Pass Fail <br />ass Fail Pass );ail <br />Pass Fail <br />Signature <br />Secondary Pi in <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 />White — Original Yellow — Arco Environmental Compliance Pink — Contractor <br />