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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 T1:Unleaded 87 T2 Diesel DFR 2. Product stored Gas Diesel DFR 3. Spill bucket capacity 5 Gallons 5 Gallons 4. Manufacturer OPW OPW E Single-walled E Single-walled ❑Single-walled ❑Single-walled ❑Single-walled ❑Single-walled 5. Construction ❑Double-walled ❑Double-walled ❑Double-walled ❑Double-walled E Double-walled ❑Double-walled N Hydrostatic ❑p Hydrostatic E Hydrostatic ❑Hydrostatic E Hydrostatic ❑Hydrostatic E Vacuum ❑Vacuum E 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 E. Product ❑p Product ❑Product 0 Product ❑Product ❑Product 7. Spill bucket type ❑Vapor ❑vapor E Vapor ❑Vapor ❑Vapor ❑Vapor 8. Liquid and debris removed from spill bucket:' Yes E No 09 Yes ❑No E Yes ❑No ❑Yes E No ❑Yes ❑No E Yes E No 9. Visual inspection (No cracks,loose parts or separation of the bucket from the fill pipe.)? ©Pass ❑Fail 0 Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fall ❑Pass ❑Fail ❑Pass ❑Fall 10. Tank riser cap included in test? [5 Yes ❑No❑NA [5 Yes ❑No❑NA ❑Yes E No❑NA ❑Yes ❑No❑NA ❑Yes ❑No❑NA ❑Yes ❑No❑NA 11. Is drain valve Included In test? IN Yes ❑No❑NA I]Yes ❑No❑NA ❑Yes ❑No❑NA ❑Yes ❑No❑NA ❑Yes ❑No❑NA ❑Yes ❑No❑NA 12. Starting level 12.00" 13.50" 13. Test start time 12:00 pm 12:00 pm 14. Ending level 12.00" 13.50" 15. Test end time 1:00 pm 1:00 pm 16. Test period 1 hour 1 hour 17. Level chane 0 0 Test results: ®Pass ❑Fail 9 Pass ❑Fail E Pass ❑Fail E Pass ❑Fall ❑Pass ❑Fall ❑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 name: �� °^�°° �•^°° Tester's name: Garrett Warren Date : 1/14/2020 Tester's signature: GPH=Gallons per hour,Y=Yes,N=No,NA=Not applicable,VPH=Vacuum/Pressure/Hydrostatic,ID=Identification