Attachment 3.7.1 TR-WM-141 UST Corrosion Protection Test Form.pdf
PDF 244 KB Posted
- Attached to
- Facility Maintenance Services at Fort McCoy, WI
- Solicitation number
- W912ES22R0011
About this file
This document contains a form for testing underground storage tank corrosion protection in Wisconsin. The form requires information on the tank owner and facility, the tester, and test results including voltage readings and pass/fail for each tank and pipe. Test criteria include -0.850 volts for galvanic or 100 mV polarization for impressed current systems. If tests are inconclusive, a corrosion expert evaluation is required within 30 days. Testers must note rectifier settings if applicable and include a diagram showing tank and pipe locations and test point numbers. Repairs are required if protection is inadequate and must be completed by the noted date.
This solicitation is for facility maintenance services at Fort McCoy, Wisconsin. The contractor shall provide maintenance, repairs, and preventive maintenance for facilities, utilities, equipment and areas identified by service orders or preventive maintenance schedules to keep them fully functional for their intended use. Work includes maintaining all facility and building components, devices, equipment and subsystems in accordance with manufacturer manuals. The soliciting agency is the Department of the Army Corps of Engineers Engineering District St Paul.
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Text version
TR-WM-141 (2/17) Formerly ERS-10785 FOR OFFICE USE ONLY
Wisconsin Department of Agriculture, Trade and Consumer Protection
Bureau of Weights and Measures
P.O. Box 7837, Madison, WI 53707-7837
(608) 224-4942
UST CORROSION PROTECTION TEST/SURVEY REPORT
Wis. Admin. Code §ATCP 93.100
Personal information you provide may be used for purposes other than that for which it was originally collected (s. 15.04(1)(m) Wis. Stats.).
OWNER INFORMATION
CUSTOMER NAME:
COMPANY NAME:
TELEPHONE:
E-MAIL:
STREET ADDRESS:
CITY VILLAGE TOWN
STATE
ZIP
SITE INFORMATION
FACILITY NAME:
FACIILITY ID#:
ASSIGNED ANNIVERSARY MONTH
DATE OF TESTING/SERVICING
CITY VILLAGE TOWN
TESTER INFORMATION
SUBMITTING PARTY:
CONTACT PERSON
WORK ORDER #:
TELEPHONE:
CELL PHONE:
E-MAIL:
TESTER NAME: SURVEY TYPE:
Wisconsin Certification Type: Routine Re-Survey Post-Repair or Modification Post-Installation
Wisconsin Certification #: TYPE OF SYSTEM: Impressed Current Galvanic
CP CRITERION APPLIED: -0.850 volts “ON” (Galvanic) 100 mV Polarization (Impressed) -0.850 volts “INSTANT-OFF” (Impressed)
SECTION I: Tester’s evaluation (mark only one)
PASS
All protected structures at this site pass the cathodic protection survey and it is judged that adequate cathodic protection has been provided to the UST system. Complete Section III.
FAIL
One or more protected structures at this site fail the cathodic protection survey and it is judged that adequate cathodic protection has not been provided to the UST system. Complete Section III.
INCONCLUSIVE
If the remote and the local do not both indicate the same test result on all protected structures (both pass or both fail), inconclusive is indicated and the survey must be evaluated and/or conducted by a corrosion expert. Go to Section II.
CP TESTER (Print): CP TESTER’S SIGNATURE:
SECTION II: Corrosion expert’s evaluation (mark only one)
The survey must be conducted and/or evaluated by a corrosion expert when: a) supplemental anodes or other changes in the cathodic protection system are made; b) stray current may be affecting buried metallic structures or c) an inconclusive result was indicated.
PASS
All protected structures at this site pass the cathodic protection survey and it is judged that adequate cathodic protection has been provided to the UST system. Complete Section III.
FAIL
One or more protected structures at this site fail the cathodic protection survey and it is judged that adequate cathodic protection has not been provided to the UST system. Complete Section III.
COMMENT:
CORROSION EXPERT’S NAME (Print): CORROSION EXPERT’S NAME
COMPANY NAME:
WISCONSIN CORROSION EXPERT CERTIFICATION #:
REVIEW DATE:
CITY
SECTION III: Action required as a result of this evaluation (mark only one)
NONE Cathodic protection is adequate. Test again within regulatory window or by: (DATE):
REPAIR & RETEST
Cathodic protection is not adequate. (Corrosion Expert evaluation in Section II is required if adding supplemental anodes, impressed current, or if stray current is suspected.) Repair/modification is necessary by:
(DATE):
TESTING INDICATES INCONCLUSIVE Wisconsin Corrosion Expert evaluation required within 30 days : (DATE):
TR-WM-141 (2/17)
Formerly ERS-10785
FACILITY NAME: DATE:
Rectifier Info: VOLTS AMPS: SETTINGS COARSE: FINE:
Anode Output: TOTAL:
POTENTIAL MEASUREMENTS
TEST
LOCATION
NUMBER
DESCRIPTION
(i.e. Tank A–White (REG) Fill End)
CONTACT POINT
(i.e. Tank Bottom or Test Lead)
HALF CELL
PLACEMENT
(i.e. Soil over Tank)
ON
READING
(VOLTS)
INSTANT-
OFF
(VOLTS)
DEPOL NATIVE
DATE:
mV Polarized
(100mV
Criteria)
STRUCTURE to
CONDUIT or REC
NEGATIVE
(VOLTS)
Pass/
Fail
Formerly ERS-10785 FACILITY NAME: DATE:
Rectifier Info: VOLTS AMPS: SETTINGS COARSE: FINE:
Anode Output: TOTAL:
POTENTIAL MEASUREMENTS
TEST
LOCATION
NUMBER
DESCRIPTION
(i.e. Tank A–White (REG) Fill End)
CONTACT POINT
(i.e. Tank Bottom or Test Lead)
HALF CELL
PLACEMENT
(i.e. Soil over Tank)
ON
READING
(VOLTS)
INSTANT-
OFF
(VOLTS)
DEPOL NATIVE
DATE:
mV Polarized
(100mV
Criteria)
STRUCTURE to
CONDUIT or REC
NEGATIVE
(VOLTS)
Pass/
Fail
Formerly ERS-10785 FACILITY NAME: DATE:
Provide a drawing or use the space below:
NOTES: 1) Measurements shall be taken over tank(s); Minimum 3 tank top/ 1 remote.
2) One measurement shall be taken for every 10 feet of piping length.
Include Service Station Diagram that shows all Tanks and Dispensers in relation to Buildings and Streets. Include on the drawing the location of the Submersible Pumps, Fills, ATGs, Risers, and Vents. If this is an Impressed Current System, show Rectifier location.
Clearly indicate on diagram where all Test Readings were taken by identifying each structure being tested (UST by Product Stored or
Product Piping by Tank/Dispenser) and numbering each individual test location. Show on drawing if corrosion test leads and/or test stations exist for the USTs or product piping and their location. Show locations of all reference electrodes. Indicate North on the drawing.
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