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Secondary Containment Testing Report Form - Page 2 of 5 D. Testing of Tank Annular Spaces/Vaults ® N/A (No tanks have secondary containment) Test Method Developed By: E] Tank Manufacturer; ® Industry Standard; E] PE; E] Other (Specify): Test Method Used: ❑ Pressure; ® vacuum; ❑ Hydrostatic; ❑ Other (Spec): Test Equipment Used: gauge Equipment Resolution: 0.5" HG pipe Run #: Sat #3 Pipe Run #: Sat #1 Tank #: Tank #: Tank #: DSL Tank #: Is Tank Exempt From Testing? ❑ Yes; ® No ❑ Yes; ❑ No ❑ Yes; ❑ No ❑ Yes; ❑ No Tank Capacity (gallons): 20,000 Diesel Diesel Diesel Diesel Product/Grade Stored in Tank: DSL 30 Min. 30 Min. 30 Min. Test Start Date/Time: Tank Manufacturer: Unknown 1:40 1:40 Initial Reading (Rj): 5.1 PSI Tank Model: Unknown Test End Date/Time: 10:45 11:37 Wait time between applying pressure/vacuum/water and starting test (minutes): 30 Min 5.1 PSI 5.2 PSI 5.1 PSI 0.0 PSI Test Start Time: 8:10 0.0 PSI 0.0 PSI 0.0 PSI Pass/Fail Threshold or Criteria: Initial Reading (RI): 10" HG 0.0 PSI 0.0 PSI Test Result: ® Pass; ❑ Fail Test End Time: 10:10 Final Reading (RF): 10" HG Change in Reading (RF— Rj): 0.0" HG Pass/Fail Threshold or Criteria: 0.0" HG Test Result: ® Pass; ❑ Fail ❑ Pass; ❑ Fail ❑ Pass; ❑ Fail ❑ Pass; ❑ Fail Was leak detection sensor properly replaced and verified as functional after testing? ® Yes; ❑ No; ❑N/A (Not Removed) ❑ Yes; ❑ No; E]N/A (Not Removed) ❑ Yes; ❑ No; ❑ N/A (Not Removed) ❑ Yes; ❑ No; E]N/A (Not Removed) E. Testing of Secondary Piping or Containment Trenches ❑ N/A (No piping 20 containment) Test Method Developed By: ❑ Pipe/Trench Manufacturer; ® Industry Standard; ❑ PE; ❑ Other (Spec): Test Method Used: ® Pressure; ❑ vacuum; ❑ Hydrostatic; ❑ Other (Specify): Test Equipment Used: gauge Equipment Resolution: 0.2 PSI pipe Run #: Sat #3 Pipe Run #: Sat #1 Pipe Run #: DSL Sec. to Dis 2/4 Pipe Run #: DSL Sec. to Disp 1/3 Pipe/Trench Manufacturer: Environ Environ Environ Environ Pipe/Trench Model: Enviroflex Enviroflex Enviroflex Enviroflex Product/Grade in Line: Diesel Diesel Diesel Diesel Wait time between applying pressure/vacuum/water and starting test (minutes): 30 Min. 30 Min. 30 Min. 30 Min. Test Start Date/Time: 9:45 10:37 1:40 1:40 Initial Reading (Rj): 5.1 PSI 5.2 PSI 5.1 PSI 5.0 PSI Test End Date/Time: 10:45 11:37 2:40 2:40 Final Reading (RF): 5.1 PSI 5.2 PSI 5.1 PSI 0.0 PSI Change in Reading (RF — Rj): 0.0 PSI 0.0 PSI 0.0 PSI 0.0 PSI Pass/Fail Threshold or Criteria: 0.0 PSI 0.0 PSI 0.0 PSI 0.0 PSI Test Result: ® Pass; ❑ Fail ® Pass; ❑ Fail ® Pass; ❑Fail ❑ Pass; ® Fail UN -054 - 2/5 www.unidocs.org 02/26/02