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Reminvanded PraNca for the lening and Vmfiatim of Sp;t OvedB, telt OetodOn and Secondary Contynmern Equipmsm at UST fi dwes PEURP1200-17 - - ----- - ---- APPENDIX C4 l ', fadsgrvame; oamer. Appendix C contains sample test data sheets that can be used when conducting testing and verfficatim of spi 1, over- Address: Aaaress fill, leak detection and secondary mnLelnment equipment, shear vahes and emergency steps at underground storage , yyata cop code: pry, cute, Zip code: tank IM facilities. Electronic wisions of the forms also ere aYailable at wnnny pei.orp/rp1200. Fac$ly I.D. B: Plana t. Appendix C (pages 46 - 56) contains the following data sheets Testing company: Phone B: Date: • Appel CL' Tank Secondary CwdainmeM Integrity Testing Dry Test Method Thtadata sheal6 (w testYtgine kNegdq dine dry secondary cOtdaFnment N a underground storage tank NST), See HVRP1200 Section 4.2 fm IMLest procedure. • Append'a G2: Piping SecondwYCeintairvnent lnterVilyTesting Tanktmmbar • Appendix CS: 6p6 Bucket lnbV4 Testing Hydmstatk Test Method Single and Doubler\Veiled , Tank Material Vacuum Test Method Pmdud stoned • Appendix CA: Contalnmerd Sump lntegdtyTesting Hydmstadc Testing Method Tank apaaty,• ppnans • Appendix O5: LIST (hwfill Equipment Inspection AxAnmatic Shutoff Device and Bali Float Valve Test slartnme Inoue! 1'ecuum Reading, • Appendbx 06: Overfill Alarm Operation inspection Indees Ng (See Tame • Appendix C7: Automatic Tank Gauge Operation Inspection d-i Dekwy Specified Test Duration ❑ ilcor OShour 0 hour 0 how 131 Mur 131 or • Appendix C8: Liquid Sera" wnctlonalttyTesting (Sae To me e-1 below.) 02 MVR 0 hours 02 hours 13 haws 0 hours 02 Mine • Append OB: MochaNcal and ElecUoric lice Leak Detectors Performance Tests Test FixdTOM '... R nchalnt esHNg • Append C-10: ShearVal\n Operation inspection Inches • Appendix C-it, Emergerdy Strip Swdtrh Operation Inspection Is the Annular space ❑Yes ONO ❑Yes ONO Dyes 0140 Ores ONO Dyes OND ❑Yes ONO Dry After Na Test? Test Results ❑Pass OFdg OPd53 OFag OPass Of it I ❑ Pass Dead! ❑ Pass OFeg ❑ Pass ❑ Fad Minims Vacuum, Capacity, Dumtinn, inches Hg gallons noun <20,000 ••• 1 20,000e 2 '.. Comments: '. •Totaltank wRazrry, Ududing ea wmparlmenos lnamuNmmpaNnent lank Tester's Name (Pito) Testers Signature ® p pei.org ei.org Retcvmxeded Praeftes for theTasung andVed aidon of Spal, omit teak Detecicn and Semndany Cwraintnmt Equiptmnt at UST fauces 'kr' PEIVRP1200-17 APPENDIX C*3 Fadwty Name: r Dnner. Fadfty Name: 0aner. Addfesc Address: Aridness: Manu: dLY. stat;, Zip cone: ply'.sate, Z$ case: dry. State, ZIP Code: ply, State, Zip Code: Fee" W. M. Phone /: Testing Compar - Phone B: ate: Fealty I.D. g: Phone e: Tons procedure b lO test the leak integrity d en®e- find doubaxa9ed spill buckets. See PF/RP1200 Section 6.2 for l innate de test TssWg company. Phone 9: Date: m:ied. Se<UOn6.3len dngbwa&tl tacuvm test method aid 5actbn fiA for daumaweCsd sacrum test melted. Tank Number This procedure is wassi the We" of the werstpW space of doubt vruk 1plaint Sae PD/RP1200 Section 5 for Na test '.. pmdud Staetl procedure. ',...,,.... Split BucMl Tek Number ap ay Piping Run Atanuinturer ( NPIng A•aierial CasswUlon ODDUNavralkd ❑ Doublo-waged ODoniU B a led ❑ Doume-%eOed ODoubkxeikd ODOutlevaIled l Productstwed Test TM OH)dnostatk ❑ Hydrostatic OH)dmstatk OHadnoddic 0hwrostatk; 11Hydmstatic I Owcuum ❑Vacwm Owcwm Owawm ❑Vawum ❑wcuum Tont wart Time OSin@eweaed OSInVa Iled OSIno"siletl Og'nglei\apad 0S!ngktwged OSInglewaPetl ODuals%vlied O ❑ Ooubrelied OCwUem lied ODcuble-W 21ed ItiuTerslPressure, ps $ SpitBueiadTyOPradd ❑ Pmtlud ❑Produt OPmdvd ❑ Poduct ❑ Produc ecedurespecMes OVapor OwpOr Oww Ow O\4Mf ❑wpr bpd$) LiquWariddTest Fnd Ifee re .ed from Oyes OLIO ❑vas ONO Oy ONO OYss ONO Oyes Oto Oyes [Ilia Flml Test Pressure, ps�g copal Docket?` Pressure charge (NO 040cocks, loom ed inspection reduction in Pressure Vo elkmedforpass.) para iuoc sepasa- ❑ Pass 13 Fal ❑ Paas OFad ❑ Pass OFal ❑ Pass ❑ FePo ❑ Pass ❑ Fail ❑ Pass ❑ fail Lan done buc ed TestResults ❑ Pass OFfl ❑ Pass Until ❑ Pass OFaa ❑ Pass Ofag ❑ Pass ❑ Fan ❑ pass Olath l from e i0 pipe.) Camnenb Tank inner sup Oyes ONO Oyes ONO Dyes ONO Dyes Oto Oyes ONO Dyes ❑ coo Included In Leel? OVA Ota 0N OIDI ❑ fiA ❑ ILA DraM wire OYes ONo Dyes ONO Oyes Oso O'w'es ONo Oyes ONO Oyes ONO Included in Lear? ❑ NA ❑ m OtiA 0N 01 ❑ m smiting Larval Tess Start Time Ending LnH Tan Ftd Time Test Period Level Change Pass/faii crAeda: Must Pau v'aual Inspection. HrdmsUtle: \ester kvd drop of less than 1/6 inch; waaum sirg[ - Wed only: Malma!n at load 26 bichos nater column; Vacuum double %aikd: maintain at least 12 Wnes water column. Test Results OPam 0Fa3 1 ❑ Pass OFaft Cl Pass 0N ❑ Pass OFail ❑ Pass ❑ Fel OPdss OFaPo Comments: *AS Melds and dells mud be d'sposed Of properly. Testers Name (pint) Testers Signature Tester's Name (prim) Tester's Signature pei.org pei.org