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—And Storage Tank system Tanks,Piping,:& Spill Buckets <br /> ,3econdary Containment Certification Form Page of _L <br /> Facility#: Testing Contractor: -e . --✓+ TestDate: -� <br /> s J <br /> Facility Address:. �_ ` 0 A ,`S Contractor Address:Gi ) �/ 5 .•��a. Tech.Name: Cvr�f� <br /> USTAnnularS ace <br /> Secondary Pi in <br /> Tank 41 Tank #2 Tank.#3 Tank#4 Line#1 Line #2 Line#3 Line#4 <br /> Product 7189 91 D 87 9, 91 D 87 89 e)D 87 89 D Product 87 89 91 D 87 89 .91 D 87 89 91 7 89 91 D <br /> .� <br /> Capacity ,�' • r (iT < f i Piping Type Primary Siphon Primary Siphon Primary Siphon Primary Siphon <br /> Manufacturer Manufacturer - <br /> . Start Time�:1. r Test Start Time <br /> InitialPtessure Initial Pressure <br /> Test End Time-, <br /> Test End Time 11 U s , <br /> Final Pressure <br /> .Final Pressure �.—�i •�"' `� <br /> Test Results`•. ass Fail ss Fail ass Fail Pass Fail <br /> Test Results ogs�`-� Fail ass Fail ass Fail P3s�s Fail <br /> Signature C <br /> Signature LJ. <br /> Spill Buckets ,. <br /> Overfill#1 Overfill#2 Overfill#3 Overfill Seconds Pi in ; -_- ;' - •0vr <br /> Product 7 9 91 D 87 (091 D 87'89 OD 87 8 91 D Line 45 Lige#6 Line#7 Line#8 <br /> Product 87C9,191D 87.89 D ��91 D 87 89-91 DManufacturer ''> � ^ ... -- <br /> f'rM P J-0t7i e-G• eGD ` <br /> Piping Type Primary.Siphon Primary Siphon Primary Siphon Primary Siphon <br /> `art Time(to) ✓ j` -'� P g yP <br /> ater Level F,,-,;., t-, ;�.+. I'�tr '1 <br /> . �.. .(,_ ,��,.v, Manufacturer <br /> Time(ti) a "< s 3 ; 1 <br /> Water Level �^ Test Start Time t,; .. a,r� <br /> Time 02) ; 5~{� 1 ' �'_ 6 Initial:Pressure <br /> Water Level <br /> 70 f '' 'I(; .Test End Time •� i ii i <br /> D <br /> ( (13. <br /> j . <br /> Time(t3) �._ ;.} •Cr <br /> Water Level t G?t; Final Pressure <br /> Time 04) i: G 2-^ ` 1'.`:;2. Test Results (�ass� Fail ass Fail Passe Fail ass i Fail <br /> Water Level 0C�r; ,� <br /> .,%� Signature <br /> Test Results .P :%' Fail ;Pass_ Fail rPa,�ss% Fail . Pass Fail <br /> .. Signature �. <br /> Y <br /> Rev. 11/01 White-Original Yellow-Arco Environmental Compliance Pink-Contractor <br /> L <br />