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CGRS UST Spill Bucket SOLUTIONS DELIVERED • • Integrity Testing Form Underground Storage Tanks ( UST) Program Instructions on Page 3 Purpose : This procedure is to test the leak integrity of single - and double -walled spill buckets . See reverse side for basic hydrostatic testing instructions . Consult PEI/RP1200 , Section 6. 2 for hydrostatic test method , Section 6 . 3 for single-walled vacuum test method , and Section 6 .4 for double -walled vacuum test method . Testing Information 1 . Tank number TI : 87 T2 Diesel 2 . Product stored Gas Diesel 3 . Spill bucket capacity 5 Gallons 5 Gallons 4. Manufacturer OPW OPW 9 Single-walled N Single-walled ❑ Single-walled ❑ Single-walled ❑ Single-walled ❑ Single-walled 5. Construction ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled N Hydrostatic Fg] Hydrostatic ❑ Hydrostatic ❑ Hydrostatic ❑ Hydrostatic ❑ Hydrostatic ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Single-walled ❑ Single-walled ❑ Single-walled ❑ Single -walled ❑ Single-walled ❑ Single -walled 6 . Testtype ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled N Product I] Product ❑ Product ❑ Product ❑ Product ❑ Product 7 . Spill bucket type ❑ Vapor ❑ Vapor ❑ Vapor ❑ Vapor ❑ Vapor ❑ Va or 8 . Liquid and debris removed from spill bucket:` E Yes ❑ No E Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No 9. Visual inspection (No cracks, loose parts or separation of the bucket from the rill pipe.)? Rl Pass ❑ Fail 9 Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail 10. Tank riser cap included in test? 0 Yes ❑ No ❑ NA O Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA 11 . Is drain valve included in test? 0 Yes ❑ No ❑ NA Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA 12. Starting level 13.75' 13.50" 13. Test start time 8:07 am 8:07 am 14. Ending level 13.75" 13.50" 15. Test end time 9:07 am 9:07 am 16. Test period 1 hour 1 hour 17. Level chan e 0 0 Test results : p Pass ❑ Fail N Pass [] Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail Pass/fail criteria : Must pass visual inspection. Hydrostatic: Water level drop of less than 1/8 inch; Vacuum single-walled only; Maintain at least 26 inches water column; Vacuum double-walled; maintain at least 12 inches water column. Comments : * All liquids and debris must be disposed of properly . Testing company � CGRS Garrett Warren name : Tester s name : Date . 1 / 17/20 Tester's signature : - v = GPH = Gallons per hour, Y = Yes, N = No, NA = Not applicable, VPH = Vacuum/Pressure/Hydrostatiq ID = Identification