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03/13/2012 15:24 0000000 0�@�������@@E��� PAGE 05/06 <br /> Secondary Containment Testing Report Form-Page 4 of 5 <br /> an, <br /> Z4 <br /> Dispenser# Dispenser Dispenser# <br /> Is UDC Exempt from Testing? ❑yes; No ❑Yes; ❑No Yes; No ❑Yes; No <br /> UDC Manufacturer: Bravo <br /> UDC Model: Bravo <br /> UDC Depth: 12" <br /> Height from UDC Bottom to Top NA <br /> of Highest Pii Penetration: <br /> Height from UDC Bottom to NA <br /> Lowest Electrical Penetration: <br /> Portion of UDC Tested Entire <br /> If turbine shuts down when UDC 13 N/A <br /> sensor detects liquid,specify NIA El wA CJ WA <br /> turbine shutdown response time, minutes, minutes. minutes. minutes, <br /> Wait time between applying <br /> pressure/vacuum/water and iS minutes, mimucs. mimx". minutm. <br /> starting test <br /> Test Start Date/Time: 9:07 9:29 <br /> initial Reading(R,): 0.691 0.692 <br /> Test End Date,Time: 9:22 9:44 <br /> Final Reading(RF): 0.690 0.693 <br /> Change in Reading(Rr—R,): 0.001 0.001 <br /> Pass/Fail Threshold or Criteria: 0.002 <br /> Test Result: 0 Pass; LJ Fail 0 Pass; El Fail Pass; Fail ❑Pass; Fail <br /> Was leak detection sensor <br /> properly replaced and verified as ❑Yes; ❑No; ❑Yes;❑No; ❑Yes; ❑ No; ❑Yes;❑No; <br /> functional after testis ? ❑N/A(Not Removed) ❑N/A(Nm Removed) ❑N/A(Nm Removed) ❑N/A(Not Removed) <br /> H. Testing of Fill Riser Containment Sumps ❑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(S ecrjy): <br /> Test Method Used: ❑Pressure; ❑Vacuum; ❑Hydrostatic; M Other(Spec!& <br /> Test Equipment Used: Equipment Resolution: <br /> Sump#: Sump#: Sump#: Sump#: <br /> Sump Diameter(inches): <br /> Sump Depth(inches): <br /> Portion of Sump Tested <br /> Sump Material: <br /> Wait time between applying <br /> ptessure/vacuum/water and <br /> starting test(minutes): <br /> Test Start Date/Time: <br /> Initial Reading(R,): <br /> Test Frid Date/Time: <br /> Final Reading(Rr): <br /> Change in Reading(Rr—R,): <br /> 2' If the entire depth of the UDC is not tested,specify how much was tested. If the answer to <br /> s0y of the questions indicated with an <br /> asterisk(')is"NO"or"N/A",the entire UDC must be tested. is=swRcts Low!Guidance Let=1(7•1601 <br /> UN-054-415 "W.adidocs.orR <br /> 02!20/03 <br />