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11 <br />Secondary Containment Testing Report Form - Page 5 of 5 <br />Pass/Fail Threshold or Criteria: <br />Test Result: Pass; El Fail <br />0 Pass; ❑ Fail <br />❑ Pass; El Fail <br />El Pass; El Fail <br />Was leak detection sensor <br />❑Yes; El No; <br />F1 Yes; F1 No; <br />❑Yes; El No; <br />❑Yes; ❑ No; <br />properly replaced and verified as <br />E]N/A (Not Removed) <br />❑ N/A (Not Removed) <br />Q N/A (Not Removed) <br />[:]N/A (Not Removed) <br />functional after testing? <br />I. Testing of Spill Buckets ❑ N/A (No spill buckets installed) <br />❑ Spill bucket(s) not tested <br />Test Method Developed By: ❑ Bucket Manufacturer; ❑ Industry Standard; ❑ PE; ❑ Other (Spec): <br />Test Method Used: ❑ Pressure; ❑ Vacuum; ❑ Hydrostatic; ❑ Other (Specie): <br />Test Equipment Used: Equipment Resolution: <br />Bucket #: Bucket #: Bucket #: Bucket #: <br />Bucket Diameter: <br />Bucket Depth: <br />Wait time between applying <br />pressure/vacuum/water and <br />starting test: <br />Test Start Time: <br />Initial Reading (Rt): <br />Test End Time: <br />Final Reading (RF): <br />Change in Reading (RF — Rt): <br />Pass/Fail Threshold or Criteria: <br />Test Result: ❑ Pass; ❑ Fail ❑ Pass; ❑ Fail Q Pass; ❑ Fail ❑ Pass; ❑ Fail <br />J. Additional Information <br />Were any repairs made to secondary containment systems prior to testing? es (describe in "Comments"); ❑ No <br />Were any secondary containment systems unable to be tested? ❑ Yes (describe in "Comments"); ❑ No <br />Is any follow-up action recommended? ❑ Yes (describe in "Comments"); ❑ No <br />Was any cleaning of secondary containment systems done? ❑ Yes (describe management of wastewater in "Comments" ); ❑ No <br />If hydrostatic testing was performed, describe in "Comments" what was done with the water after completion of testing. <br />N <br />UN454 - 515 www.usidecs.org 02/26/02 <br />