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Secondary Containment Testing Report Form Page 4 of 5 <br /> Dispenser# Dispenser# Dispenser# Dispenser# <br /> Is UDC Exempt from Testing? Yes; No Yes; No Yes; No ❑Yes; No <br /> UDC Manufacturer: <br /> UDC Model: <br /> UDC Depth: <br /> Height from UDC Bottom to Top <br /> of Highest Piping Penetration: <br /> Height from UDC Bottom to <br /> Lowest Electrical Penetration: <br /> Portion of UDC Tested' <br /> If turbine shuts down when UDC N/A ❑N/A ❑N/A ❑N/A <br /> sensor detects liquid,specify minutes. minutes. minutes. minutes. <br /> turbine shutdown response time. <br /> Wait time between applying <br /> pressure/vacuum/water and minutes. minutes. minutes. minutes. <br /> starting test <br /> Test Start Date/Time: <br /> Initial Reading(R,): <br /> Test End Date/Time: <br /> Final Reading(RF): <br /> Change in Reading(RF—114): <br /> Pass/Fail Threshold or Criteria: <br /> `Est 4= ASS;" mil "'TOP 134i$ �. <br /> Was leak detection sensor <br /> properly replaced and verified as 0 Yes;El No; ❑Yes;❑No; El Yes;ED No; ❑Yes;❑No; <br /> functional after testin ? ❑N/A(Not Removed) ❑N/A(Not Removed) El N/A(Not Removed) ❑N/A(Not Removed) <br /> H. Testing of Fill Riser Containment Sumps ❑N/A(No fill riser sumps) <br /> ❑Fill Riser Containment Sumps are Present,but were Not Tested <br /> Test Method Developed By: ❑Sump Manufacturer,❑Industry Standard;❑PE;❑Other(Specify): <br /> Test Method Used: ❑Pressure; ❑Vacuum; ❑Hydrostatic; ❑Other(Spec): <br /> Test Equipment Used: Equipment Resolution: <br /> At koJ <br /> t Er r <br /> -T" <br /> Sump#: Sump#: Sump#: Sump#: <br /> Sump Diameter(inches): <br /> Sump Depth(inches): <br /> Portion of Sump Tested <br /> Sump Material: <br /> Wait time between applying <br /> pressure/vacuum/water and <br /> starting test(minutes): <br /> Test Start Date/Time: <br /> Initial Reading(Ri): <br /> Test End Date/Time: <br /> Final Reading(RF): <br /> Change in Reading(RF—R,): <br /> 2. If the entire depth of the UDC is not tested,specify how much was tested. If the answer to any of the questions indicated with an <br /> asterisk(*)is"NO"or"N/A",the entire UDC must be tested. [See SWRCB Local Guidance Letter LG-160] <br /> UN-054-4/5 www.unidocs.org 02/26/02 <br />