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= 4 UST Spill Bucket SOLUTIONS OELIVERr= O 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 T2 89 T3 87 T4 Diesel 2 . Product stored Unleaded Unleaded Diesel 3 . Spill bucket capacity 5 Gallons 5 Gallons 5 Gallons 4. Manufacturer OPW OPW OPW ❑ Single -walled ❑ Single-walled ❑ Single-walled ❑ Single-walled ❑ Single -walled ❑ Single-walled 5. Construction ® Double-walled ® Double-walled ® Double-walled ® Double-walled ❑ Double-walled ❑ Double-walled ® Hydrostatic ® Hydrostatic ® Hydrostatic ❑ Hydrostatic ❑ Hydrostatic ❑ Hydrostatic ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Single-walled ❑ Single-walled ❑ Single -walled ❑ Single-walled ❑ Single-walled ❑ Single-walled 6 . Test type ❑ Double-walled ❑ Double-walled ❑ Double -walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ® Product N Product ® Product ® Product ❑ Product ❑ Product 7 . Spill bucket type ❑ Vapor ❑ Vapor ❑ Vapor ❑ Vapor ❑ Vapor ❑ Vapor 8 . Liquid and debris removed from spill bucket:* ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No 9. Visual inspection (No cracks, loose parts or separation of the bucket from the fill i e.)? ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail 10 . Tank riser cap included in test? ® Yes ❑ No ❑ NA ® Yes ❑ No ❑ NA ® Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA 11 . Is drain valve included in test? ® Yes ❑ No ❑ NA ® Yes ❑ No ❑ NA ® Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA 12. Starting level 13 .50" 13.50" 13.50" 13. Test start time 10 : 00am 10 : 00am 10 : 00am 14. Ending level 13.50" 13.50" 13.50" 15. Test end time 11 : 00am 11 :00am 11 : 00am 16. Test period 1 hour 1 hour 1 hour 16. Level chane 0 0 0 Test results : ® Pass ❑ Fail ® 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 name : CGRS Tester's name : Garrett Warren Date : 1 -8 -2020 Tester's signature :