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r<= \� CG RS 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 PEIIRP1200, 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 87 89 91 2. Product stored Unleaded Unleaded Unleaded 3. Spill bucket capacity Under 5 gallons 5 gallons Under 5 gallons 4. Manufacturer OPW OPW OPW 9 Single-walled N Single -walled 9 Single-walled ❑ Single -walled ❑ Single-walled ❑ Single-walled 5. Construction ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Hydrostatic ❑ Hydrostatic 9 Hydrostatic ❑ Hydrostatic ❑ Hydrostatic ❑ Hydrostatic ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Single-walled ❑ Single-walled ❑ Single-walled ❑ Single-walled ❑ Single -walled ❑ Single-walled 6. Testt pe ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled N Product NJ Product i] Product ❑ Product ❑ Product ❑ Product 7. Spill bucket type ❑ Vapor ❑ Vapor ❑ Vapor ❑ Vapor ❑ Vapor ❑ Vapor 8 . Liquid and debris removed from spill bucket: * [!] Yes ElNo 0 Yes El No ff Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No i 9. Visual inspection (No cracks , loose parts or separation of the bucket from the fill i e.)? R Pass ❑ Fail ❑ Pass X Fail 0 Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail 10. Tank riser cap included in test? [9 Yes ❑ No ❑ NA © Yes ❑ No ❑ NA 3 Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA 11 . Is drain valve included in test? E Yes ❑ No ❑ NA i] Yes ❑ No ❑ NA O Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA 12. Starting level NA NA NA 13. Test start time NA NA NA 14. Ending level NA NA NA 15. Test end time NA NA NA 16. Test period NA NA NA 17. Level chap e NA NA NA Test results : ❑ Pass ❑ Fail ❑ Pass 9 Fail ❑ Pass 9 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 : W7 °«,vE" Tester's name : Date : 3-25-2019 Tester's signature : GPH = Gallons per hour, Y = Yes, N = No, NA = Not applicable, VPH = Vacuum/PressurelHydrostatic, ID = Identification