Form SFN60641 "Ust Cathodic Protection System Evaluation Galvanic (Sacrificial Anode) Type" - North Dakota

What Is Form SFN60641?

This is a legal form that was released by the North Dakota Department of Health - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2018;
  • The latest edition provided by the North Dakota Department of Health;
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  • Fill out the form in our online filing application.

Download a fillable version of Form SFN60641 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Health.

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Download Form SFN60641 "Ust Cathodic Protection System Evaluation Galvanic (Sacrificial Anode) Type" - North Dakota

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rd
UST CATHODIC PROTECTION SYSTEM EVALUATION
918 East Divide Avenue, 3
Floor
Bismarck, ND 58501-1947
GALVANIC (SACRIFICIAL ANODE) TYPE
Telephone: 701-328-5166
NORTH DAKOTA DEPARTMENT OF HEALTH
Fax: 701-328-5200
Clear Form
DIVISION OF WASTE MANAGEMENT
www.ndhealth.gov/wm
SFN 60641 (5-2018)
Instructions: Within 30 days, send completed form to:
North Dakota Department of Health
Division of Waste Management
918 E Divide Ave 3rd Fl
Bismarck ND 58501-1947
ND UST ID Number
All reports must be submitted regardless of results (pass, fail, or inconclusive).
Incomplete, unsigned, or illegible forms will not be accepted and will be returned.
1. UST FACILITY
2. UST OWNER/OPERATOR
Name
Name
Address
Address
City
State
ZIP Code
City
State
ZIP Code
County
Telephone Number
County
Telephone Number
Name of Contact
Telephone Number
Name of Contact
Telephone Number
3. CATHODIC PROTECTION (CP) TESTER INFORMATION AND QUALIFICATIONS
Name of Tester
Name of Company
Address
City
State
ZIP Code
Telephone Number
E-mail Address
Steel Tank Institute (STI) Certification Number
National Association of Corrosion Engineers
(NACE) International Certification Number
4. TEST REQUIREMENTS
Reason Test Was Conducted (check one)
Routine - 3 year
Routine - within 6 months of install
30-day re-survey after fail
Re-survey within 6 months of repair/modification
DATE NEXT SURVEY MUST BE CONDUCTED BY:
(required within 6 months of installation/repair and every 3 years)
5. EVALUATION
CP Tester's Evaluation (check one)
All protected structures at this facility pass the CP survey and the continuity survey indicates all protected structures are
Pass
isolated. It is judged that adequate CP has been provided to the UST system. (Complete Sections 7 and 8.)
One or more protected structures at this facility fail the CP survey, and it is judged that adequate CP has not been provided to
Fail
the UST system. (Complete Sections 7 and 8.)
The remote and the local do not both indicate the same test result on all protected structures (both pass or both fail),or the
Inconclusive
continuity survey indicates continuous or inconclusive results when compared to non-protected structures, the survey must be
evaluated by a corrosion expert. (Corrosion expert to complete Section 6.)
Date CP Test Performed:
rd
UST CATHODIC PROTECTION SYSTEM EVALUATION
918 East Divide Avenue, 3
Floor
Bismarck, ND 58501-1947
GALVANIC (SACRIFICIAL ANODE) TYPE
Telephone: 701-328-5166
NORTH DAKOTA DEPARTMENT OF HEALTH
Fax: 701-328-5200
Clear Form
DIVISION OF WASTE MANAGEMENT
www.ndhealth.gov/wm
SFN 60641 (5-2018)
Instructions: Within 30 days, send completed form to:
North Dakota Department of Health
Division of Waste Management
918 E Divide Ave 3rd Fl
Bismarck ND 58501-1947
ND UST ID Number
All reports must be submitted regardless of results (pass, fail, or inconclusive).
Incomplete, unsigned, or illegible forms will not be accepted and will be returned.
1. UST FACILITY
2. UST OWNER/OPERATOR
Name
Name
Address
Address
City
State
ZIP Code
City
State
ZIP Code
County
Telephone Number
County
Telephone Number
Name of Contact
Telephone Number
Name of Contact
Telephone Number
3. CATHODIC PROTECTION (CP) TESTER INFORMATION AND QUALIFICATIONS
Name of Tester
Name of Company
Address
City
State
ZIP Code
Telephone Number
E-mail Address
Steel Tank Institute (STI) Certification Number
National Association of Corrosion Engineers
(NACE) International Certification Number
4. TEST REQUIREMENTS
Reason Test Was Conducted (check one)
Routine - 3 year
Routine - within 6 months of install
30-day re-survey after fail
Re-survey within 6 months of repair/modification
DATE NEXT SURVEY MUST BE CONDUCTED BY:
(required within 6 months of installation/repair and every 3 years)
5. EVALUATION
CP Tester's Evaluation (check one)
All protected structures at this facility pass the CP survey and the continuity survey indicates all protected structures are
Pass
isolated. It is judged that adequate CP has been provided to the UST system. (Complete Sections 7 and 8.)
One or more protected structures at this facility fail the CP survey, and it is judged that adequate CP has not been provided to
Fail
the UST system. (Complete Sections 7 and 8.)
The remote and the local do not both indicate the same test result on all protected structures (both pass or both fail),or the
Inconclusive
continuity survey indicates continuous or inconclusive results when compared to non-protected structures, the survey must be
evaluated by a corrosion expert. (Corrosion expert to complete Section 6.)
Date CP Test Performed:
SFN 60641 (5-2018)
Page 2 of 7
Name of Facility
Test Date
6. CORROSION EXPERT’S EVALUATION (if applicable)
A Corrosion Expert is needed to evaluate certain metal structures. See Appendix A at the end of this form for more information.
All protected structures at this facility have been evaluated to have adequate CP provided to the UST systems.
Pass
One or more protected structures at this facility fail the CP survey and it has been evaluated that adequate CP has not been provided to
Fail
the UST system.
Name of Corrosion Expert
Telephone Number
Name of Corrosion Company
NACE Int./PE Certification
NACE Int./PE Certification Number
Signature of CP Expert
Date
7. EVALUATION CRITERIA
Criteria Applicable to Evaluation (check all that apply)
Structure-to-soil potential more negative than -850 millivolts (mV) with respect to a reference cell with the protective current applied.
850 On
Other method allowed by the NDDoH UST Program. Please describe:
Other
8. ACTION REQUIRED
Action Required as a Result of this Evaluation (check only one)
CP is adequate. No further action is necessary at this time. Test again by no later than (see Section 4).
None
CP may not be adequate. Retest within 30 days to determine if passing results can be achieved.
Retest
(Retests may occur only if all protected structures are isolated from non-protected structures.)
Repair and Retest
CP is not adequate. Repair/modification is necessary within the next 60 days; or permanently close the tank system.
9. CP SYSTEM REPAIRS AND/OR MODIFICATION INFORMATION
Date of "Failing" Test
Date of Repair
Name of Repair Company
Name of Lead Repair Technician
Telephone Number
Certification of Repair Technician (check all that apply)
Note: submit failing test results with this report
Steel Tank Institute
NACE
Description of Repairs (check all that apply)
Repairs/modifications for 1 and 2 must be
1. Supplemental anodes for a sti-P3® tank.
designed by a "corrosion expert" or installed
2. Supplemental anodes for metallic pipe which is factory coated with dielectric material (fusion
per industry standards.
bonded epoxy or equivalent).
3. Supplemental anodes for a non-sti-P3® tank (e.g., bare steel).
Repairs/modifications for 3 and 4 must be
designed and evaluated by a "corrosion expert"
4. Supplemental anodes for metallic pipe which is non-factory coated with dielectric material
only.
(e.g., galvanized, copper, bare steel, etc.)
5. Isolation of galvanically protected tanks/piping (explain in “remarks/other” below).
6. Isolation of non-protected metal pipe segments (e.g., flex connectors) at STP or dispenser sumps (explain in “remarks/other”).
Remarks/Other
SFN 60641 (5-2018)
Page 3 of 7
Name of Facility
Test Date
10. GALVANIC (SACRIFICIAL ANODE) STRUCTURE TO SOIL POTENTIAL AND CONTINUITY SURVEY
Structure to Soil Potentials:
Half Cell Placement (testing) on frozen soil, concrete, asphalt, or other paving materials is not acceptable.
The half cell must be placed in a minimum of three locations per tank, and three locations per piping run. At least one of the
reference cell locations must be in the soil directly over the tested structure (local); and at least one must be placed in soil
approximately 25 to100 feet away from the structure (remote). The third location is at the discretion of the tester (either local
or remote).
When testing flex connectors only, two tests points are required for each flex connector, one local and one remote. If separate
corrosion protection is required on flex connectors, treat each flex as if it were an individual metal pipe when recording results.
Both the local and the remote voltage must meet the -0.85 volts criteria in order for the structure to pass.
Inconclusive must be indicated when both the local and the remote structure-to-soil potentials do not result in the same
outcome (both pass or both fail).
Continuity Testing: (Point-to-Point and/or Fixed Cell-Moving Ground):
Point-to-Point: When conducting this method, the leads of the volt meter are required to contact the two structures being
examined to demonstrate isolation or continuity. A half cell is not used for this test method.
Fixed Cell-Moving Ground: When conducting this method, the half cell must be placed in the soil at a remote location
approximately 25 to100 feet away and left undisturbed. The other lead of the meter is moved to structures being evaluated.
To interpret continuity data for either method compare the difference in voltage of the structures evaluated and use the
following guidelines: 1 mV or less = continuous, 1-10 mV= inconclusive, greater than 10 mV = isolated.
For galvanic systems, the structure that is to be protected must be isolated from all other non-protected metallic structures in
order to “pass” the continuity survey.
If other approved continuity testing methods are used, alter this form or submit the data on a separate sheet.
Describe soil type and location(s) of remote reference cell placement(s)
(e.g., Black Dirt, 30 feet NW of Tank #1 spill bucket):
Remote Location #1
Remote Location #2
Example for Recording Results
Structure to Soil Potentials (mV)
Continuity Testing (mV)
Half Cell
Point-to-
Fixed Cell
Isolated/
Site Map
Half Cell Placement Description
"ON" Voltage
Structure Tested
Point
Remote
Continuous/
Code
Voltage
Voltage
Inconclusive
Tank 1- 10,000 gallon premium
Structure:
L1
Local, Soil at ATG manway
-1011 mV
ATG Conduit
475 mV
Isolated
L2
Local, Soil at STM manway
-995 mV
STPG Conduit
-528 mV
Isolated
R1
Remote #1
-1042 mV
Vent
421 mV
Isolated
Tank Bottom
Fill Riser
375 mV
-522 mV
Isolated
Structure Contact Point(s):
Pass
Fail
Inconclusive
Overall Structure Results (structure to soil potentials and continuity):
Number 10 continued on next page
SFN 60641 (5-2018)
Page 4 of 7
Name of Facility
Test Date
Structure to Soil Potentials (mV)
Continuity Testing (mV)
Half Cell
Point-to-
Fixed Cell
Isolated/
Site Map
Point
Remote
Continuous/
Half Cell Placement Description
"ON" Voltage
Structure Tested
Code
Voltage
Voltage
Inconclusive
Structure:
Overall Structure Results (structure to soil potentials and continuity):
Pass
Fail
Inconclusive
Structure:
Structure Contact Point(s):
Overall Structure Results (structure to soil potentials and continuity):
Pass
Fail
Inconclusive
Structure:
Structure Contact Point(s):
Pass
Fail
Inconclusive
Overall Structure Results (structure to soil potentials and continuity):
Structure:
Structure Contact Point(s):
Pass
Fail
Inconclusive
Overall Structure Results (structure to soil potentials and continuity):
SFN 60641 (5-2018)
Page 5 of 7
Name of Facility
Test Date
Structure to Soil Potentials (mV)
Continuity Testing (mV)
Half Cell
Point-to-
Fixed Cell
Isolated/
Site Map
Half Cell Placement Description
"ON" Voltage
Structure Tested
Point
Remote
Continuous/
Code
Voltage
Voltage
Inconclusive
Structure:
Structure Contact Point(s):
Pass
Fail
Inconclusive
Overall Structure Results (structure to soil potentials and continuity):
Structure:
Structure Contact Point(s):
Overall Structure Results (structure to soil potentials and continuity):
Pass
Fail
Inconclusive
Structure:
Structure Contact Point(s):
Overall Structure Results (structure to soil potentials and continuity):
Pass
Fail
Inconclusive
Comments
Attach additional sheets as needed
Page of 7