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PEVRP1200 -17 <br /> APPENDIX <br /> TANW-SECONDARY tONTAINIVI <br /> DRY rr <br /> Facility Name: Owner: <br /> Address: Address: <br /> City, State, Zip Code: City, State, Zip Code: <br /> Facility I . D. #: Phone #: <br /> Testing Company: Phone #: Date: <br /> This data sheet is for testing the integrity of the dry secondary containment of a underground storage tank (UST) . See PEVRP1200 <br /> Section 4.2 for the test procedure. <br /> Tank Number <br /> Tank Material <br /> Product Stored <br /> Tank Capacity,* gallons <br /> Test Start Time <br /> Initial Vacuum Reading, <br /> inches Hg (See Table <br /> 44 below.) <br /> Specified Test Duration ❑ 1 hour ❑ 1 hour 111 hour 111 hour ❑ 1 hour ❑ 1 hour <br /> (See Table 41 below.) 112 hours ❑ 2 hours ❑ 2 hours ❑ 2 hours ❑ 2 hours ❑ 2 hours <br /> Test End Time <br /> Final Vacuum Reading, <br /> inches Hg <br /> Is the Annular Space ❑ Yes ❑ No ❑ Yes ❑ No [] Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Dry After the Test? <br /> Test Results ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass 0 Fail [] Pass ❑ Fail <br /> TABLE 4�1 <br /> Vacuum, Capacity, Duration, <br /> Inches Hg gallons hours <br /> <20,000 1 <br /> 10 <br /> 20,000+ 2 <br /> Comments: <br /> *Total tank capacity, including all compartments in a multi-compartment tank, <br /> Tester's Name (print) Tester's Signature <br /> pel. org <br /> E <br /> i <br />