Facility Name Facility ID Address Tester’s Name Test Date Phone Type of Dispenser Dispenser Dispenser Dispenser Dispenser Dispenser Transition Transition Transition Transition Transition Transition containment Tank Top Tank Top Tank Top Tank Top Tank Top Tank Top Sump Sump ID (eg. dispenser #, tank location, product, etc) Sump Material Construction Single walled Single walled Single walled Single walled Single walled Single walled Double walled Double walled Double walled Double walled Double walled Double walled Liquid and debris Yes Yes Yes Yes Yes Yes No No No No No No removed Visual Inspection Pass Pass Pass Pass Pass Pass Fail Fail Fail Fail Fail Fail No cracks, holes or separations. Containment Sump Depth Height from bottom to top of highest penetration Start Level Start Time Ending Level End Time Test Period (Minimum of 1 hour) Water Level Change Test Results Pass Pass Pass Pass Pass Pass Fail Fail Fail Fail Fail Fail Photos indicating water levels attached? Pass/fail criteria: Must pass visual inspection, test duration at one hour, must include photos with this form, water level drop of less than 1/8 inch. Ref: PEI/RP 1200 6.5 Test Method How was the liquid disposed?
Facility Name Facility ID Address Tester’s Name Test Date Phone Type of containment Sump Dispenser Transition Tank Top Dispenser Transition Tank Top Dispenser Transition Tank Top Dispenser Transition Tank Top Dispenser Transition Tank Top Dispenser Transition Tank Top Sump ID (eg. dispenser #, tank location, product, etc) Sump Material Construction Single walled Double walled Single walled Double walled Single walled Double walled Single walled Double walled Single walled Double walled Single walled Double walled Liquid and debris removed Yes No Yes No Yes No Yes No Yes No Yes No Visual Inspection No cracks, holes or separations. Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Containment Sump Depth Height from bottom to top of highest penetration Start Level Start Time Ending Level End Time Test Period (Minimum of 1 hour) Water Level Change Test Results Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Photos indicating water levels attached? Pass/fail criteria: Must pass visual inspection, test duration at one hour, must include photos with this form, water level drop of less than 1/8 inch. Ref: PEI/RP 1200 6.5 Test Method How was the liquid disposed?
DERR-2017-008725.docx