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Udergrbund Storage Tank System Turbine Sumps,Fill Sumps and Under Dispenser Containment <br /> Secondary Containment Certification Form Page i of <br /> Facility#: (00&0 City: �'0[� Testing Contractor: 2yA, Test Date: 3 8 Z <br /> FacilityAddress: �, ! Q�� 6 9'17 5 4e/m- Cf- Tech.Name: 38 H <br /> a UA,-x ` Contractor Address: <br /> Turbine Sumps 89 91 D 87 C> 91 D 87 89 D 87 89 91 Fill Sumps 87 89 91 D 87 89 91 D 87 89 (91> <br /> ,87 89.—PI D <br /> ID(north,slave,etc.) ID north slave etc. L.olarip/ <br /> Manufacturer Manufacturer <br /> 1 <br /> ' - '1 1 ' <br /> Start Time(to) Start Time(to) <br /> Water Level d•CV0 0.000 Water Level - f0• <br /> -1e(t]) 1 12.- I I-f Time(t,) 'Zl I : V 2,; Z -! S 3 <br /> ter Level O-CO (p- Doo Q,coo Water Level 0.000 b- W I n-000 C9.00 <br /> Time 02) 1' ,. 110 1 1 Z.5 112 Time 02) 1, s ZO -V. Z 5' 0-! c <br /> Water Level -0.00' 0-007— eqzvo Water Level P-000 ©-VOO 0 -0tv, 0.00 2 <br /> Time 03) 01 . 1.3 1 t- 17 W63 Timet <br /> ( 11. 2-7 11: i'. 31 '- <br /> 3) <br /> Water Level "Qfoa?.©©I Affa Water Level .CO ) -0-coI ^O. v -00 1 <br /> Time 04) LI: 12 1,ZD Irl.+'- 5b Time 04) ( , 30 7". <br /> Water Level ^m. f -0-0191 6?-W Water Level V-WO r 0.1c 1 , 00 7— <br /> Test <br /> Test Results Fail ass Fail . Fail Pass Fail Test Results a Fail s Fail ass Fail ass Fail <br /> Signature G, }�►�"' �_ �-{� ,f SignatureL,� -- <br /> UDC _ UDC <br /> ID(1/2,3/4,etc.) '— — 3-q 5- & 7—8 ID(1/2,3/4,etc.) <br /> Manufacturer Manufacturer <br /> _.rt Time(to) / Start Time(to) <br /> W� <br /> 6 • p t <br /> Water Level ©• -o V-1000 Q. Wb 10, con Water Level <br /> Time(tt) ' !G 6-:3.3 9 t Time(tt) <br /> Water Level Q(7 - 1. 31-2, 0. 000 O0 Water Level <br /> Time 02) 51".3 % & ' 10 Time 02) <br /> Water Level 0D Water Level <br /> Time 03) �• S^: r �0% ZG Time(t3) <br /> Water Level (4. 000 CoQ Water Level <br /> Time 04) t / S►' -I' ` % Time 04) <br /> Water Level .Coo OQO Water Level <br /> Test Results Pass Fail Pass FailPass Fail ass Fail Test Results Pass Fail Pass Fail Pass Fail Pass Fail <br /> Signature � _ � G Signature <br /> . Rev. 11/01 White-Original Yellow-Arco Environmental Compliance Pink-Contractor <br />