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Secondary Containment Testing Report orm - Page 4 of 5 <br />H. Testing of Fill Riser Containment Sumps <br />❑ N/A (No fill riser sumps) <br />❑ Fill Riser Containment Sumps are Present, but were Not Tested <br />Dispenser # 6/7 <br />Dispenser # <br />Dispenser # <br />Dispenser # <br />Is UDC Exempt from Testing? <br />❑Yes; ®No <br />El ®No <br />El ❑ No <br />❑Yes; ❑ No <br />UDC Manufacturer: <br />Bravo <br />Bravo <br />UDC Model: <br />Bravo <br />Bravo <br />UDC Depth: <br />12" <br />12" <br />Height from UDC Bottom to Top <br />of Highest Piping Penetration: <br />NA <br />NA <br />Height from UDC Bottom to <br />Lowest Electrical Penetration: <br />NA <br />NA <br />Portion of UDC Tested" <br />Entire <br />Entire <br />Entire <br />If turbine shuts down when UDC <br />sensor detects liquid, specify <br />turbine shutdown response time. <br />® N/A <br />minutes. <br />® N/A <br />minutes. <br />❑ N/A <br />minutes. <br />❑ N/A <br />minutes. <br />Wait time between applying <br />pressure/vacuum/water and <br />starting test <br />15 minutes. <br />15 minutes. <br />minutes. <br />minutes. <br />Test Start Date/Time: <br />3:08 3:23 <br />3:08 3:26 <br />Initial Reading (Rj): <br />0.467 0.468 <br />1.943 1.943 <br />Test End Date/Time: 1 <br />3:23 3:41 <br />3:23 3:41 <br />Final Reading (RF): <br />0.467 0.468 <br />1.943 1.943 <br />Change in Reading (RF — Rt): <br />0.00 0.00 <br />0.00 0.00 <br />Pass/Fail Threshold or Criteria: <br />0.002 <br />0.002 <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 as <br />functional after testing? <br />Yes No <br />® � ❑ � <br />❑ N/A (Not Removed) <br />®Yes; ❑ No; <br />ElN/A (Not Removed) <br />Yes; No; <br />❑ ❑ <br />❑ N/A (Not Removed) <br />Yes; No; <br />❑ ❑ <br />❑ N/A (Not Removed) <br />H. Testing of Fill Riser Containment Sumps <br />❑ 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 (Spec): <br />Test Method Used: ❑ Pressure; ❑ Vacuum; ❑ Hydrostatic; ❑ Other (Specie): <br />Test Equipment Used: <br />Equipment Resolution: <br />Sump #: <br />Sump #: <br />Sump #: <br />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 (R,): <br />Test End Date/Time: <br />Final Reading (R17): <br />Change in Reading (RF — R,): <br />If the entire depth of the UDC is not tested, specify how much was tested. If the answer to aM 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 />IJN-054 - 4/5 www.unidoes.org 02/26/02 <br />