Regional Ofices

Storage Tank System

Test Form Mount Pearl (709) 729-
Harbour Grace (709) 945-
Test Certification Form as Clarenville 3107
(709) 466-
required Gander 4060
(709) 256-
Grand Falls-Windsor 1420
(709) 292-4206
under The Storage and Corner Brook (709) 637-2204
Handling of Happy Valley-Goose (709) 896-5428
Bay
Gasoline and Associated Products
Regulations

Information
1 Name of Tank Owner or Operator

Address

Tank Serial Number

Date of Test

Test Performed By Company Affiliation of Tester

Reason for Test (please check) Type of Test Used (please check)
2 New or altered or repaired system set into Hydrostatic (Underground systems)
operation Request 48 hour dip (aboveground vertical
from Department 3 systems) Visual (Overhead
System being Horizontal Tanks) Pressure
abandoned (Piping Systems)
Storage Tank System in Electrical Potential (Cathodic Protection
critical area Storage Tank Systems) Percolation
System in sensitive area Other (Dyking Systems)
(specify) Other (specify)

Information
4 Attach a sketch of all storage tank systems at location, indicating which systems were tested.
Test Results (please
check) Undetermined Leak in Storage Tank Dyke Permeability Satisfactory
5 Leak in Tank
System

System Liquid Tight Electrical Potential

Leak in Satisfactory
Piping Hydrostatic A. Duration of Test
Test
Pressur Litres Accum. Percolation Test Result:
Time
e Injected or Temp.
o Vol.
(Kilopascals Drained C Change
B. Final Accum. Vol. Change: L
2
/m /d

C. Result (B/A): Electrical Potential Measured:

mV

48 Hour Dip Dip Pressure Test o

Test Time Readin Litres Change Temp. C
g
 Dip o
Time Readin Litres Change Temp. C
g

I / We certify that the information supplied on this form is complete and accurate.

Tester Date Storage Tank System

Owner or Operator

02 01 70 009c_2014 05