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Underground Storage Tank System Tanks,Piping,& Spill Buckets <br /> Secondary Containment Certification Form Page-L of -� <br /> Facility City: ��-OC 11'n�1ro✓�. Testing Contractor:_ �t'�{-�.r�. ;R ti�,in Test Date:. <br /> U <br /> Facility Address: ��(�(p �t L !J(�(Lrj�Q Contractor Address: (9� �"� S t,T rc� Co LAO-Tech.Name: GiR- i i (✓G.. <br /> UST Annular Sp ace econdary Piping <br /> Tank#1 Tank #2 Tank 93 Tank#4 Line#1 Line #2 Line#3 Line#4 <br /> Product . 87 89 BD @) 89 91 D 87 89 91 D 7 89 91 D Product 87 89(9'!)D 7 89 91 D 87 89 91 D (D89 91 D <br /> Capacity Piping Type im Siphon rimary Siphon rimary Siphon Primary Sipho <br /> Manufacturer t Rk t` Manufacturer <br /> w\i <br /> Test Start Time ; Nue- <br /> "O -1 r..vt i- <br /> U•U � � t � .2. Test Start Time pll. :t � �_ s . •z�, iZosSvlC'sL ( ; 0 <br /> Initial Pressure 't l�G �u �, u h <br /> Uc-c' O Initial Pressure �.- <br /> Test End TimeD; 1 U� (� ® Test End Time 00, <br /> Final Pressure Final Pressure <br /> Test Results ass Fail s Fail Pas Fail Pass Fail S tis <br /> Signature <br /> Test Results Pass. Fail Pass Dai (Lai) ass Fail <br /> �. -® <br /> Signature _ <br /> Spill Buckets <br /> Overfill#1 Overfill#2 Overfill#3 Overfill#4 Second Pi in <br /> Product 87 89 91 D 1 89 91 D 8 89 91 D 87 9 91 D Line#5 Line #6 Line#7 Line#8 <br /> Product 8 89 91 D 87 89 91 D 87 89 91 D 87 89 91 D <br /> Manufacturer Nw,CU> D�cSt,. wtc <br /> Piping Type Primary Sipho Pri ary Siphon Primary Siphon Primary Siph <br /> Start Time(to) '1 �S3c6�`'3- S$:2-5� �.LIT �' <br /> Water Level 060 10(b (900 i 000. Manufacturer <br /> w.t <br /> Time(t,) `1 $ <br /> e6"21 1 V Test Start Time <br /> Water Level <br /> - 000 . 000 C> a►r 0 0.1 <br /> Time(t2) O 1 'iS 1 3 l $ Initial Pressure d ,14=n <br /> Water Level �"' �� � ' S S 1 _ i '� ., <br /> ' b 000 W D Test End Time ®'r <br /> Time(t,) OW C6'- I„I <br /> Water Level �Oi SOW fi p0 fi �G S- <br /> o <br /> Final Pressure PS <br /> Time(t4) `�io"? ° �-� �'. 3-7 v6 ! S7 Test Results Pa Fail Pass lffiaw FWWE%*1E'Aff4 Fail <br /> Water Level "' Qca- ,u(71 1- (y '00— Signature .n <br /> Test Results Pass Fail as Fail Fail Fail <br /> Signature - <br /> r <br /> Rev. 11/01 White-Original Yellow-Arco Environmental Compliance Pink-Contractor <br />