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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: ❑Tank Manufacturer;❑Industry Standard;❑PE;❑Other(Spec): Test Method Used: ❑Pressure; ❑Vacuum; ❑Hydrostatic; ❑Other(Specie): Test Equipment Used: Equipment Resolution: Tank#: Tank#: Tank#: Tank#: Is Tank Exempt From Testing? ❑Yes; ❑No ❑Yes; ❑No ❑Yes; ❑No ❑Yes; ❑No Tank Capacity(gallons): Product/Grade Stored in Tank: Tank Manufacturer: Tank Model: Wait time between applying pressure/vacuum/water and starting test(minutes): Test Start Time: Initial Reading(Rj): Test End Time: Final Reading(RF): Change in Reading(RF—Rt): Pass/Fail Threshold or Criteria: Test Result: ❑Pass; ❑Fail ❑Pass; ❑Fail ❑Pass; ❑Fail ❑Pass; ❑Fail Was leak detection sensor properly replaced and verified ❑Yes;El No; ❑Yes;❑No; ❑Yes;❑No; ❑Yes;El No; as functional after v ❑N/A(Not Removed) El N/A(Not Removed) E]N/A(Not Removed) ED N/A(Not Removed) E. Testing of Secondary Piping or Containment Trenches ❑N/A(No piping 21 containment) Test Method Developed By: ❑Pipe/Trench Manufacturer; Industry Standard;❑PE;❑Other(Spec): Test Method Used: Pressure; ❑Vacuum; ❑Hydrostatic; ❑Other(Spec): Test Equipment Used: SSEquipment Resolution:12 5 Pipe Run#: Pipe Run#: Pipe Run#: Pipe Run#: Pipe/Trench Manufacturer: Pipe/Trench Model: Product/Gradein Line: Wait time between applying pressure/vacuum/water and starting test(minutes): �✓ M Test Start Date/Time: / Initial Reading(Rj): IAS I Test End Date/Time: Final Reading(RF): i Change in Reading(RF—RI): 0 Pass/Fail Threshold or Criteria: tjo, sof 5 Test Result: ❑Pass; ❑Fail ❑Pass; ❑Fait Pass; ❑Fail ❑Pass; ❑Fail UN-054-2/5 www.unidocs.org 02126/02