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Underground Storage Tank Secondary Containment Testing Report Form 16. TANK SECONDARY CONTAINMENT TEST Test Method Developed by ❑ Manufacturer 0 Industry Standard ❑ Professional Engineer Test Type ❑ Pressure 0 Vacuum ❑ Hydrostatic Test Equipment Used: 4 Inch Dial Gauge Tank ID 0001OU001 Annular UG0100001 Return UG0100001 Vent Tank Manufacturer Modern Welding Western Fiberglass A.O. Smith Tank Capacity 1000 gallons 9:27 AM 9:00 AM Test Start Time 9:00 AM 5 Psi 5 Psi Initial Reading -10 Hg 10:27 AM 10:00 AM Test End Time 10:00 AM 5 Psi 5 Psi Final Reading -10 Hg 0 0 Change in Reading 0 0 0 Pass/Fail Criteria 0.002 ❑✓ Pass ❑ Fail I ❑✓ Pass ❑ Fail ❑ Pass ❑ Fail Tightness Test Results ❑✓ Pass ❑ Fail I ❑ Pass ❑ Fail I ❑ Pass ❑ Fail I ❑ Pass ❑ Fail 7. PIPE SECONDARY CONTAINMENT TEST Test Method Developed by ❑ Manufacturer ❑✓ Industry Standard ❑ Professional Engineer Test Type ❑✓ Pressure ❑ Vacuum ❑ Hydrostatic Test Equipment Used: 4 Inch Dial Gauge Pipe Run ID UG0100001 Supply UG0100001 Return UG0100001 Vent Pipe Manufacturer Western Fiberglass Western Fiberglass A.O. Smith Test Start Time 9:27 AM 9:27 AM 9:00 AM Initial Reading 5 Psi 5 Psi 5 Psi Test End Time 10:27 AM 10:27 AM 10:00 AM Final Reading 5 Psi 5 Psi 5 Psi Change in Reading o 0 0 Pass/Fail Criteria o 0 0 Tightness Test Results ❑✓ Pass ❑ Fail ❑✓ Pass ❑ Fail I ❑✓ Pass ❑ Fail ❑ Pass ❑ Fail Pipe Run ID Pipe Manufacturer Test Start Time Initial Reading Test End Time Final Reading Change in Reading Pass/Fail Criteria Tightness Test Results ❑ Pass ❑ Fail ❑ Pass ❑ Fail I ❑ Pass ❑ Fail ❑ Pass ❑ Fail Additional copies of this page may be attached. All tests marked "Fail' and any repairs made before or during the tightness test must be described in the COMMENTS section. Page 2 of 5