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Underground Storage Tank System Tanks,Piping, & Spill Buckets <br /> Secondary Containment Certification Form Page of 2 <br /> Facility#: City: -`+Da tt'l Testing Contractor: _ Test Date: �Zq -02 <br /> Facility Address: 10C) N {+W'f q q /POVnMfe)k Contractor Address: 56.LkkA QT—. Tech.Name: 5.C..� W(,DOP'e <br /> CD <br /> m UST Annular Sp ace econdary Pi in <br /> Tank#1 Tank 42 Tank#3 Tank#4 Line#1 Line #2 Line#3 Line#4 <br /> N Product 87 89 91 D 089 91 D 87 89(n D 87 89 91 D Product 8 89 91 D B7 89 91 D 87 89 91 D 87 89 91 D <br /> N <br /> Capacity Piping Type Siphon Primary iphon Primary iphon Primary Siphon <br /> Manufacturer O Manufacturer lbvw� �� <br /> Test Start TimeArl 1L N Test Start Time 'I SAO 15-0 .15- t l 45 <br /> Initial Pressure caN + kv Ka4_ b ri Initial Pressure <br /> SL 0 <br /> Test End Time <br /> Vl:�E S S Test End Time Ltxmr I s <br /> Final Pressure Final Pressure <br /> Test Results Pass Fail Pass Fail Pass Fail Pass Fail <br /> Test Results Pass Fail Pass ass Fail Pass Fail <br /> Signature <br /> Signature <br /> Spill Buckets <br /> Overfill#1 Overfill 42 Overfill#3 Overfill#4 Secondary Piping <br /> Product - 08991 D 8 89 91 D 87 89(91)D 87 89 91 D Line#5 Line #6 Line#7 Line#8 <br /> Manufacturer �YW O P� OPhJ Product 87 89 91 D 87 89 91D 87 89 91 D 87 89 91 D <br /> Start Time(to) O I ��3 O $00 Piping Type Primary Siphon Primary Siphon Primary Siphon Primary Siphon <br /> Water Level f"�Q0170 +�pO0 (0 p00 1 Manufacturer <br /> Time(tr) 0-715 0-733 0:903 Test Start Time <br /> Water Level "141100031 4-p p ( ", Coo IV j / — I <br /> Time(t2) <br /> 07 Z( 400?3(o O © Initial Pressure <br /> Q Water Level 4-,000(09 ,OGb�Z O 00 7 f71 Test End Time <br /> Time (t3) 7ZY 073 O O <br /> Water Level *t 000 Q + 00(0q 0`d l �{ ( Final Pressure <br /> o Time(t4) 0 72 7 07 Z l Z Test Results s Fail Pass Fail Pass Fail Pass Fail <br /> N Water Level °�'�OD16 ( to 0!3 oa (Q Signature <br /> Test Resultsass Fail Pass Fail ass Fail Pass Fail <br /> Signature <br /> Rev. 11/01 White 0 i �alYellow-Arco Environmental Compliance Pink-Contractor <br />