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Underground Storage Tank System Tanks, Piping, & Spill Buckets U <br /> Secondary Containment Certification Form Page of <br /> CD <br /> Facility#:(oD@0 City: Testing Contractor: -t' L -�'��✓t �� Test Date:-- iJ 2 <br /> Facility Address: „ flU•�iS�- Contractor Address:r0) 7 �Ji�''s���` Tech.Name: 11 <br /> Lo 0 <br /> UST Anr:velar S ace Secondary P' in -�'v L �� N <br /> Tank 91 Tank #2 Tan1c#3 Taak#4 Line 91 Line #2 Line#3 Line IN <br /> Product 89 91 D 87 91 D 87 89 (DD 87 89 1 D Product 87 89 91 D 87 89 91 D 87 89 91 7 9 91 D <br /> r <br /> to <br /> Capacity [ i l f i Piping Type Primary Siphon Prinimy Siphon Primary Siphon Primary Siphon CD <br /> u <br /> Manufacturer Manufacturer <br /> Test Start Time n f Test Start Time 0;O 140'. 7-0 !0'33 1 :21. <br /> Initial Pressure Initial Pressure <br /> Test End Time Test End Time I ! QS^' i ; Z-Q 118, 33 •Id <br /> Final Pressure Final Pressure <br /> Test Results ass Fail s Fail ass Fail Pass Fail Test Results as Fail ass Fail ass Fail s Fail <br /> Signature &I'llc Ad— <br /> cn <br /> Signature <br /> S ill Buckets T <br /> Overfill 91 Overfill#2 Overfill#3 Overfil Seconds Pi inr9lD <br /> V <br /> Product 9 9l D 87 �91 D 87 $9 D 87 8 91 D <br /> LLine #6 Line#7 Line#S <br /> Product 8787 89 D 87.89 1 D 87 89-91 D <br /> Manufacturer oft ��� Po �� <br /> Start Time(t„) 3!/� 3 <br /> O Piping Type Primary Siphon Primary Siphon Primary Siphon Primary Sipb^ <br /> Water Level Q7.tea �.d� d� Manufacturer <br /> Time(tj) 3 % S3 L4 Test Start Thne !2 ;ZZ, k �: 30 Z. <br /> Water Level C% coo Q7. coo �� �u r) - Sn <br /> Time(t2) v <br /> r 1, L Initial Pressure <br /> i3- <br /> Water Level .000 Q ©•�� Test End Time , : ZZ, ; 3a 3 j S ;3 Z <br /> Time(t3) 14Final Pressure <br /> Water Level Qq 450c) �'CoCoo Test Results Pass Fail s Fail Pass Fail Pass Fail <br /> Time 04) ` y S ,'�y�� / <br /> Water Level ©•©til Q7 (`§k90 l/r�+� Signature C,J-. ��- <br /> Test Results Fail as Fail as12 Fail Pass Fail <br /> 0 <br /> Signature 61)T� al� U <br /> Rev. 11!01 White-Original Yellow-Arco Environmental Compliance Pink-Contractor <br />