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Secondary Containment Testing Report Form - Page 2 of 5 <br />D. of N Annular t< <br />❑ N/A (No tanks have secondary containment) <br />Test Method Developed By: ❑ Tank Manufacturer; ❑ Industry Standard; ❑ PE; ❑ Other (Spec): <br />Test Method Used: ❑ Pressure; ❑ Vacuum; ❑ Hydrostatic; ❑ Other (Sped): <br />Test Equipment Used: <br />Tank #: <br />Tank #: <br />Equipment Resolution: <br />Tank #: <br />Tank #: <br />Is Tank Exempt From Testing? <br />❑ Yes; ❑ No <br />❑ Yes; ❑ No <br />❑ Yes; ❑ No <br />❑ Yes; ❑ No <br />Tank Capacity (gallons): <br />Product/Grade Stored in Tank: <br />Tank Manufacturer: <br />Tank Model: <br />Wait time between applying <br />pressure/vacuum/water and <br />starting test (minutes): <br />Test Start Time: <br />Initial Reading (R): <br />Test End Time: <br />Final Reading (RF): <br />Change in Reading (RF — RY): <br />Pass/Fail Threshold or Criteria: <br />Test Result: <br />❑ Pass; ❑ Fall <br />❑ Pass; ❑ Fail <br />El Pass; ❑ Fall <br />❑ Pass; ❑ Fall <br />Was 1 detection sensor <br />properly replacedand verified <br />as ctional after ina? <br />[I Yes; E] No; <br />N/A Not Removed <br />® 1 <br />El Yes; ❑ No; <br />❑ N/A (Not Removed) <br />Yes; El No; <br />N/A (Not Removed) <br />El Yes; E] No; <br />[:1 NIA (Not Removed} <br />E. Testing of Secondary Piping or Containment Trenches ❑ N/A (No piping 2* containment) <br />UN -054 - 2/5 <br />www.anidoesorg <br />02/26/02 <br />