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SWRCB, January 2002 <br />-.rc " n rNxT r+ A rxT%ArU UT CUMP TFQTTNG <br />Page _ of _ <br />Facility is Not Equipped With Fill Riser Containment Sums ❑ <br />Fill Riser Containment Sumps are Present, but were Not Tested ❑ <br />Test Method Developed By: ❑ Sump Manufacturer ❑ Industry Standard I i Professional Engineer <br />❑ Other (Sped) <br />Test Method Used: ❑ Pressure ❑Vacuum ❑Hydrostatic <br />❑ Other (Specify) <br />Test Equipment Used: Equipment Resolution: <br />Fill Sump # Fill Sump # Fill Sump # Fill Sump # <br />Sump Diameter: <br />Sump Depth: <br />Height from Tank Top to Top of <br />Highest Pipmg Penetration: <br />Height from Tank Top to Lowest <br />Electrical Penetration: <br />Condition of sump prior to <br />IVEL: <br />A R 0 9 201 <br />testing: <br />Portion of sump Tested <br />Sump Material: <br />Wait time between applying <br />pressure/vacuum/water and <br />starting test: <br />FA! ,. a n1=agQT1fiCK1T <br />Test Start Time: <br />Initial Reading W: <br />Test End Time: <br />Final Readin (RF : <br />Test Duration: <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail ❑ Pass ❑ Fail <br />Chane in Reading (RrRI): <br />Pass/Fail Threshold or Criteria: <br />Test Result: <br />O Yes O No <br />❑ Yes O No [INA <br />❑ Yes ❑ No Lj NA <br />❑ Yes ❑ No <br />oyes []No ❑ NA <br />❑ Yes O No ❑ NA <br />❑ Yes ❑ No ❑ Yes I_! No <br />❑Yes O No ❑ NA ❑Yes EI No 11 NA <br />❑ Yes O No ❑ NA ❑ Yes ❑ No O NA <br />is there a sensor in the sump? <br />Does the sensor alarm when <br />either product or water is <br />detected? <br />Was sensor removed for testing? <br />Was sensor properly replaced and <br />verified functional after testing? <br />❑ yes ❑ No [INA ❑ Yes ❑ No DNA ❑ Yes []NO ❑NA 1 ❑ Yes O No ❑ NA <br />Comments (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />NO FILL SUMP FI LLS ARE D tKEU H u x Y <br />