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Secondary Containment Testing Report Form - Page 2 of 5 <br />D. Testing of Tank Annular SpacesNaults <br />n <br />® N/A (No tanks have secondary containment) <br />Test Method Developed By: ❑ Tank Manufacturer; ® Industry Standard; ❑ PE; ❑ Other (Spec): <br />Test Method Used: ❑ Pressure; ® Vacuum; ❑ Hydrostatic; ❑ Other (Specify): <br />Test Equipment Used: gauge <br />Equipment Resolution: 0.5" HG <br />Tank #: <br />Tank #: <br />Tank #: <br />Tank #: <br />Is Tank Exempt From Testing? <br />❑ Yes; ❑ No <br />❑ Yes; ❑ No <br />❑ Yes; ❑ No <br />❑ Yes; ❑ No <br />Tank Capacity (gallons): <br />Pipe/Trench Model: <br />Dualloy <br />Product/Grade Stored in Tank: <br />Product/Grade in Line: <br />Diesel <br />Tank Manufacturer: <br />Wait time between applying <br />pressure/vacuum/water and <br />starting test (minutes): <br />30 Min. <br />Tank Model: <br />Test Start Date/Time: <br />3:00 <br />Wait time between applying <br />pressure/vacuum/water and <br />starting test (minutes): <br />Initial Reading (Rt): <br />5.2 PSI <br />Test Start Time: <br />Test End Date/Time: <br />4:00 <br />Initial Reading (RI): <br />Final Reading (RF): <br />5.2 PSI <br />Test End Time: <br />Change in Reading (RF — RI): <br />0.0 PSI <br />Final Reading (RF): <br />Pass/Fail Threshold or Criteria: <br />0.0 PSI <br />Change in Reading (RF— Rj): <br />Test Result: <br />® Pass; ❑ Fail <br />Pass/Fail Threshold or Criteria: <br />❑ Pass; ❑ Fail <br />❑ Pass; ❑ Fail <br />Test Result: <br />❑ Pass; ❑ Fail <br />❑ Pass; ❑ Fail <br />❑ Pass; ❑ Fail <br />❑ Pass; ❑ Fail <br />Was leak detection sensor <br />properly replaced and verified <br />as functional after testing? <br />F-1 Yes; [—]No; <br />F-1N/A (Not Removed) <br />El Yes; F] No; <br />❑ N/A (Not Removed) <br />F-1 Yes; El No; <br />❑ N/A (Not Removed) <br />❑Yes; ❑ No; <br />E]N/A (Not Removed) <br />E. Testing of Secondary Piping or Containment Trenches ❑ N/A (No piping 2° containment) <br />Test Method Developed By: ❑ Pipe/Trench Manufacturer; ® Industry Standard; ❑ PE; ❑ Other (Specie): <br />Test Method Used: ® Pressure; ❑ Vacuum; ❑ Hydrostatic; ❑ Other (Specify): <br />Test Equipment Used: gauge <br />Equipment Resolution: 0.2 PSI <br />Pipe Run #: <br />Pipe Run #: 6 SAT <br />Pipe Run #: 7 SAT <br />Pipe Run #: <br />Pipe/Trench Manufacturer: <br />Ameron <br />Ameron <br />Pipe/Trench Model: <br />Dualloy <br />Dualloy <br />Product/Grade in Line: <br />Diesel <br />Diesel <br />Wait time between applying <br />pressure/vacuum/water and <br />starting test (minutes): <br />30 Min. <br />30 Min. <br />Test Start Date/Time: <br />3:00 <br />3:00 <br />Initial Reading (Rt): <br />5.2 PSI <br />5.2 PSI <br />Test End Date/Time: <br />4:00 <br />4:00 <br />Final Reading (RF): <br />5.2 PSI <br />5.2 PSI <br />Change in Reading (RF — RI): <br />0.0 PSI <br />0.0 PSI <br />Pass/Fail Threshold or Criteria: <br />0.0 PSI <br />0.0 PSI <br />Test Result: <br />® Pass; ❑ Fail <br />® Pass; ❑ Fail <br />❑ Pass; ❑ Fail <br />❑ Pass; ❑ Fail <br />IIN-054 - 2/5 www.unidoes.org 02/26/02 <br />