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2 2017 <br /> Secondary Containment Testing Report Form-Page 2 of 5 <br /> ENVI RON �,'.J,",ITAL HEALTH <br /> Iva"" T <br /> (No ranks ID�,a(D <br /> V��R"" <br /> D. Testing of Tank Annular Spaces/Vaults r-1 NIA secon iiy containment) <br /> Test Method�Developed By: E]Tank Manufacturer;El Industry Standard;El PE;0 Other(Specify): <br /> Test Method Used:*FPressure; 0 Vacuum; F❑-1 Hydrostatic; El Other(Specify): <br /> ] <br /> Test Equipment Used: Equipment Resolution: <br /> Tank <br /> Tank#: t TankTank#: <br /> Is T*Exempt From Testing? F1 Yes;dg-No El Yes• o El Yes; El No El Yes; El No <br /> Tank Capacity(gallons): N-L,coo 12 C70V <br /> Product/Grade Stored in Tank: Ck� <br /> Tank Manufacturer: Iryl*Aef-r, <br /> Tank Model: U� d-A 5,4 r c4AeA <br /> Wait time between applying <br /> pressurdvacuumAyate.r and r4ij <br /> starting test(minutes): <br /> Test Start Time: <br /> Initial Reading(Ri): — 10 <br /> Test End Time. It.,00 <br /> Final Reading(RF): l O —\0 <br /> Change in Reading(RF—IQ: V <br /> Pass/FailThreshold or Criteria: <br /> Test Result: 91 Pass; 0 Fail Pass; El Fail 0 Pass; 0 Fail El Pass; 0 Fail <br /> Was leak detection sensor I&Yes;0 No; Yes;0 No. 0 Yes;0 Na; El Yes;O-No; <br /> as functional after <br /> properly replaced and verified 0 N/A(Not Removed) ❑NIA(Not Removed) [].N/A(Not Removed) E]N/A(Not Removed) <br /> testing? I I <br /> E. Testing of Secondary Piping or Containment Trenches n N/A(No piping 2'containment) <br /> Test Method Developed By: El Pipe/Trench Manufacturer; Ej Industry Standard;$LPE;El Other(Specify): <br /> Test Method Used: $4 Pressure; El Vacuum; Ej Hydrostatic; El Other(specify): <br /> Test Equipment Used: Equipment Resolution: <br /> ........... <br /> Pipe Run#: 8:- ?L. Pipe Run#: q Pipe Run It <br /> Pipe Run#: <br /> Pipefriench Manufacturer: <br /> Pipe/Trench Model: <br /> Product/Grade in Line: 6+Joe+-- <br /> Wait time between applying <br /> pressure/vacuurn/water and 36 3 G <br /> starting test(minutes): <br /> Test Start Date/Time: <br /> Initial Reading(RI): C> <br /> Test End Date/Time: Z-.00 00 ^1..1 <br /> Final Reading(RF): 15 <br /> Change in Reading(RF—Bq): t6 <br /> Pass/Fail Threshold or Criteria: -& <br /> Test Result: -��ass; M Fail, CRLPass; El Fail 0 Pass; F1 Fail El Pass; El Fail <br /> UN-054-215 inyw.unidocs.org 02126102 <br />