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CGRS UST Spill Bucket <br /> so"'TI."s .E`"EAE. Integrity Testing Form <br /> Underground Storage Tanks (UST) Program <br /> Instructions on Page 3 <br /> Purpose: This procedure is to test the leak integrity of single-and double-walled spill buckets. See reverse side for <br /> basic hydrostatic testing instructions.Consult PEURP1200,Section 6.2 for hydrostatic test method, Section 6.3 for <br /> single-walled vacuum test method, and Section 6.4 for double-walled vacuum test method. <br /> Testing Information <br /> 4 Tank nanber TS:UNL T]UNL <br /> 2 Praduct sfcrad Udeaded UH-ded <br /> 1 Spill bucket mipacut, 5g11mz 5gWI- <br /> 4 mmulh v. OFW OPW <br /> O Single-walled OSingle-walled ❑Single-walled ❑Sinoewalled ❑Sinoewalled ❑Single-walled <br /> S Construction 0 Dcude-walled ❑Dauble-walled ❑Dauble-walled 0 Double-walled ❑Dauble-walled 0 Dable-walled <br /> M Hydrostatic 0 Hydrostatic 0 Hydrostatic 0 Hydrostatic 0 Hydrostatic 0 Hydedatic <br /> 0 Vacuum 0 Vacwm 0 Vacw 0 Vacuum 0 Vacuum 0 Vacuum <br /> 0 Single-walled ❑Single-walled ❑Single-wdlad ❑Simi ewaHad ❑SingewaHad 0 Single-waHad <br /> 6 Test 1 0 DcuW..alled 0 Double-walled 0 Dcuble-waHad 0 Dcubl...Had 0 Dcubl...Had 0 Dmble-waHad <br /> PmrWd I Pmdud ❑Pmdud r Pmdud ❑Pmdud Pnedud <br /> z Soil buckNt 0 V,.r 0v 0 V,.r ❑Vacs 0v a 0v <br /> S Wgdd and debris <br /> ved tram spill <br /> bucksL Yes 0 No Yes 0 No 0 Y. 0 No 10 Yes 0 No 0 Y. 0 No 0 Y. 0 No <br /> I Visual impedicn <br /> (No cracks,loose pens or <br /> sepaadan of the bucks <br /> Irian the fill 0 Pass 0 Fail 0 Pass 0 Fail OP. 0 Fail 0 Pan 0 Fal OP. 0 Fal OP. 0 Fal <br /> 10. Tank dser cap imludedin <br /> test? YnNo NA fLXjsLLH.CLHALLYH. NA LlYn No NA LlYn No NA Qjn No NA <br /> 11. Is dein valve included in <br /> test? EM Yes 0H.0 NA IE Y. 0H.0 NA DYn 0H.0 NA DYn 0H.0 NA DYn 0H.0 NA DYn 0H.0 NA <br /> 12. Startin level Il Da' 11.W' <br /> 11 Tees Yat time 1:10M 1:10M <br /> 1!. <br /> Encinglevel Il Da' 10.75" <br /> 15. Test and dine 2:10gn 210 <br /> 16 TaY penad Ihas 1M1ar <br /> n. lee a a <br /> Test results:10 Pan OFaii 0 Pan a Fail 0 Pan 0 Fail JOP. OFAI JOP. OFAI Pan Fal <br /> Pass/fail cniena:Must pass visual inspection.Nyrymstafic,Water level dmp orless than 1B inch;Vacuum single-walled only; <br /> Maintain at Mast 26 inches water m1unal;Vacuum double-wa1Md;maintain at least 12 inches water miumn. <br /> Comments: <br /> .All liquids and debris must be disposed of properly. <br /> Testing company CGRS <br /> name: di >o...�°���•°° Tester's name: Garrett Warren <br /> Date: 01/04/2019 Tester's signature:,. <br /> GR-I=Galina per hour,Y=Yes,N=Np NA=Not ipplkable,VPII=VacurrvPressvallydrmlaic,ID=ldetdficdim <br />