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SWRCB, January 2002 Page C of i <br />Facility is Not Equipped With Fill Riser Containment Sumps <br />X <br />Fill Riser Containment Sumps are Present, but were Not Tested ❑ <br />Test Method Developed By: 0 Sump Manufacturer 12 Industry Standard Professional Engineer <br />0 Other (Specify) <br />Test Method Used: <br />❑ Pressure <br />❑ Other (Spec) <br />0 Vacuum <br />Hydrostatic <br />Test Equipment Used: Caldwell Level Change Indicator <br />Equipment Resolution: 002 <br />Fill Sump # <br />Fill Sume # <br />, <br />Fill Sump # Fill Sump # <br />Sump Diameter: <br />Sump Depth: <br />Height from Tank Top to Top of <br />Highest Piping Penetration: <br />Height from Tank Top to Lowest <br />Electrical Penetration: <br />Condition of sump prior to <br />_testing: <br />Portion of Sump Tested <br />Sump Material: <br />Wait time between applying <br />water and starting test: <br />Test Start Time: <br />Initial Reading (R): <br />Test End Time: <br />Final Reading (RF): <br />Test Duration: <br />Change in Reading (RF -R,): <br />Pass/Fail Threshold or Criteria: <br />Test Result: <br />Pass 0 Fail <br />Pass ❑ Fall <br />Pass ❑ Fail ❑ Pass ❑ Fail <br />Is there a sensor in the sump? <br />Yes ❑ No <br />Yes 0 No <br />Yes ❑ No 0 Yes 0 No <br />Does the sensor alarm when <br />either product or water is <br />detected? <br />Yes 0 No 0 NA <br />Yes 0 No DNA <br />Yes 0 No 0 NA ❑ Yes 0 No DNA <br />Was sensor removed for testing? <br />Yes ❑ No ❑ NA <br />Yes 0 No ❑ NA <br />Yes 0 No DNA 0 Yes 0 No [INA <br />Was sensor properly replaced and <br />verified functional after testin . <br />Yes ❑ No ❑ NA <br />Yes 0 No 0 NA <br />Yes ❑ No 0 NA 0 Yes 0 No ❑ NA <br />Comments — (include information on repairs made prior to testing and recommended follow-up for failed tests) <br />