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PER-P1200-17 <br /> APPENDIX <br /> TANK SECONDARY <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 PEI/RP1200 <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 /> 4-1 below.) <br /> Specified Test Duration ❑1 hour ❑1 hour ❑1 hour ❑1 hour ❑1 hour 111 hour <br /> (See Table 4-1 below.) ❑2 hours 112 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 ❑Fail ❑Pass ❑Fail <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 /> 0 pei.org <br />