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SWRCB, January 2002 <br />7_ FRTT.T. RTQ17P C"nV1 -rA1rN1X4 '7V -r CYTrIVn -rr. c-rmTf1 <br />Page of <br />Facility is Not Equipped With Fill Riser Containment Sumps ❑ <br />Fill Riser Containment Sumps are Present, but were Not Tested ❑ <br />Test Method Developed By: ❑ Sump Manufacturer ❑ Industry Standard C Professional Engineer <br />— ❑Other (Specify) <br />Test Method Used: Fl Pressure a Vacuum i Hydrostatic <br />❑ Other (Specify) <br />Test Equipment Used: _ Equipment Resolution: <br />Fill Sump # <br />Fill Sump # <br />FillSump# <br />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 />pressure/vacuum/water and <br />starting test: <br />Test Start Time: <br />Initial Reading (RI): <br />Test End Time: <br />Final Reading (RF): <br />Test Duration: <br />Change in Reading (RF -RI): <br />Pass/Faif Threshold or Criteria: <br />Test Result: <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ` ❑ Fail <br />Is there a sensor in the sump? <br />❑ Yes _ No <br />❑ Yes ❑ No <br />❑ Yes _D No <br />❑ Yes ❑ No <br />either product or water is Yes ❑ N o _)NA ❑ Yes ❑ No f NA ❑ Yes ❑ No NA ❑ Yes ❑ No ❑ NA <br />detected'? <br />Was sensor removed for testing? Yes F] N o 1 NA ❑ Yes ❑ No NA E, Yes ❑ I�To ❑ NA ❑Yes ❑'`To ❑ NA <br />Was sensor properly replaced and _ <br />— <br />verified functional after testing? Yes ❑ N-0 NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No =' NA ❑ Yes ❑ No [INA <br />_ <br />Comments — (include infomiation on repairs made prior to testing and "reconrmeitded follow-up for failed tests) <br />