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Underground Storage Tarok System Tanks, Piping, & Spill Buckets <br /> Secondary Containment Certification Form Page of Z <br /> a <br /> Facility#: 6:0zo City: Nlo,v►-L-C-C4 Testing Contractor: Pe+c'-, Tcc"�- c Test Date: IU-H_d Z <br /> i <br /> Jac ar,�l <br /> Facility Address: (11( luSEwiQ Contractor Address: 5, 4!,� Tech.Name: � <br /> UST Annular Space Secondary Piping <br /> r <br /> Tank#1 Tank #2 Tank#3 Tank 44Line#1 Line #2 Line#3 Line#4 <br /> Product 87 89 91 D 87 89 91 D 87 89 91 D 87 89 91 D Product (5 89 91 D 87(D91 D 87 89 OD 87 89 91 D <br /> Capacity Piping Type Primary Siphon Primary Siphon Primary Siphon Primary Siphon <br /> Manufacturer Manufacturer <br /> • —G.i 1 A0. i <br /> Test Start Time Test Start Time a3c) <br /> Initial Pressure Initial Pressure <br /> 5.0 �S• S D f? S,D RS• <br /> Test End Time <br /> Test End Time Cl ; 30 9:30 c) <br /> Final Pressure <br /> Final Pressure S G S T <br /> Test Results Pass Fail Pass Fail Pass Fail Pass Fail <br /> as <br /> Test Results Fail � Fail as Fail Pass Fail <br /> Signature <br /> Signature <br /> Spill Buckets <br /> Overfill#1 Overfill#2 Overfill#3 Overfill#4 Seconds tin <br /> Product 87® 91 D 87 89 91 D 87 89 91 D 87 89 91 D Line#5 Line 46 Line#7 Line#8 <br /> Product 87 89 91 D 87 89 91 D 87 89 91 D 87 89 91 D <br /> Manufacturer �10a <br /> Piping Type Primary Siphon Primary Siphon Primary Siphon Primary Siphon <br /> Start Time(to) <br /> Water Level Q, Manufacturer <br /> Time(tj) �'S� Test Start Time <br /> Water Level G <br /> Initial Pressure <br /> Time(ti) <br /> Water Level p.C40 Test End Time <br /> Time 03) 9'0Z Final Pressure <br /> Water Level (i*. <br /> q � Test Results Pass Fail Pass Fail Pass Fail Pass Fail <br /> Time(t,,) <br /> Water Level G, -G Signature <br /> i <br /> Test Results as Fail Pass Fail Pass Fail Pass Fail <br /> Signature a' <br /> 1 <br /> Rev. 1 1/01 White—Original Yellow—Arco Environmental Compliance Pink—Contractor <br /> i <br />